PENINSULA DIVERSITY DIALOGUE DAY 2021 SCHOOL REGISTRATION FORM

*This form must be received by VCIC by October 20, 2021*
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)
As we will be using breakout rooms during DDD, each student will need access DDD from an individual device. Is it also recommended for students to 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 Paula L. Bazemore prior to October 15 (pbazemore@inclusiveVA.org). If you don't plan to fill all 12 spots, type N/A.

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