TIDEWATER PREJUDICE AWARENESS SUMMIT 2022 SCHOOL REGISTRATION FORM

*This form must be received by VCIC by December 22, 2021* If you have trouble filling out this form, please email Emma Cox at ecox@inclusiveVA.org
Please write out the full name of the school
Please include area code
To reach you on the day of the program (include your area code)
Check all that Apply (Based on this information, VCIC will follow up with an official application link.)
Because we will be be using breakout rooms in Zoom, each student will need to access PAS from an individual device. It is recommended that students use headphones.
If someone else other than main contact on this form plans to attend, please name that individual in the blank space and provide their email address.

PLEASE SHARE THE FULL NAMES OF THE STUDENTS YOU WOULD LIKE TO REGISTER:

All student names and completed permission forms are required prior to the program. If unable to fill in now, contact Emma Cox (ecox@inclusiveVA.org). If you don't plan to fill all 8 spots, type N/A.
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