PAS Lynchburg – Student Registration Form | Virginia Center for Inclusive Communities

2023 Lynchburg Prejudice Awareness Summit Student Information & Permission Form

Student’s First Name *

Student's Middle Name

Student's Last Name *

Name Student Prefers to be called *

School *

Please type out full name of school

Student Email *

Student Dietary Restrictions (please be specific): *

School Advisor Email

email address of school contact / educator that asked you to submit this form

Parent/Guardian Name *

Parent/Guardian Email *

Parent/Guardian Phone *

Does the student have any medical considerations that will restrict participation in program activities? *

(Note that VCIC will do our best to meet all requests.)

Yes

If yes, please explain

Medical Emergency Contact Name *

Medical Emergency Contact Relationship to Participant *

Medical Emergency Contact Phone *

Agreements

I give permission for my child to participate in the 2023 Prejudice Awareness Summit (PAS) conducted by the Virginia Center for Inclusive Communities on January 12th at Randolph College. I understand that PAS is a human relations program that deals with mature subject matters possibly including stereotypes, prejudice, communication, racism, sexism, religious bias, etc.
I understand that although the program sponsor has taken precautions to provide proper organization, supervision, instruction, and equipment for each activity, it is impossible for the sponsor to guarantee absolute safety. I also understand that each participant shares the responsibility for safety during all activities and I assume that responsibility for my child. I waive any claim that may arise against the Board of Directors of the sponsor, and/or its employees, agents, volunteers, or lessors including those claims which may arise from the negligence of the sponsor, their Board of Directors; and/or its employees, agents, lessors or volunteers.
I understand that student participants are asked to complete a written evaluation that assesses their views on human relations issues and the PAS program. I give permission for my child to complete such forms.
I give permission for my child to be photographed or videoed by sponsors and/or others approved by sponsors at the Prejudice Awareness Summit.

Parent/Guardian Printed Name *

Parent/Guardian Signature *

Sign on the line with mouse cursor or with your finger on a touchscreen.

Signature is required.

Date *