DDD Peninsula – School Registration Form

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PENINSULA DIVERSITY DIALOGUE DAY 2022 SCHOOL REGISTRATION FORM

*This form must be received by VCIC by October 7*

School Name *

Please write out the full name of the school

Principal Name *

Street Address *

Country

City

State

Zip code

School Phone *

Please include area code

Fax

Advisor Name *

Advisor Title *

Advisor Phone *

To reach you on the day of the program (include your area code)

Ext.

Email *

Would you like to be included in an advisor networking list? *

Yes

Attending advisor dietary restrictions (please be specific): *

Due to parking limitations, schools are encouraged to drop off and pick up their participants. Will you need a designated parking space for the day? *

Yes

If YES, please note the quantity and type(s) of vehicle(s):

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

In order to ensure full registration and to help us create breakout groups that are as diverse as possible, all student names and completed permission forms are required prior to the program. If unable to fill in now, contact Paula L. Bazemore prior to October 7 ([email protected]). If you don't plan to fill all 12 spots, type N/A.

1. *

(1) Gender, Grade & Race *

2. *

(2) Gender, Grade & Race *

3. *

(3) Gender, Grade & Race *

4. *

(4) Gender, Grade & Race *

5. *

(5) Gender, Grade & Race *

6. *

(6) Gender, Grade & Race *

7. *

(7) Gender, Grade & Race *

8. *

(8) Gender, Grade & Race *

9. *

(9) Gender, Grade & Race *

10. *

(10) Gender, Grade & Race *

11. *

(11) Gender, Grade & Race *

12. *

(12) Gender, Grade & Race *