Project Inclusion – Delegate Permission Form & Agreement Home 9 Programs 9 Schools 9 Project Inclusion – Delegate Permission Form & Agreement If you are human, leave this field blank.Participant Information Project Inclusion Permission Form & Participant AgreementPlease complete the form by October 28, 2022. NOTE: You cannot save your partially completed form so please review the full form before starting to complete.Participant's First Name *Participant's Middle NameParticipant's Last Name *Name student prefers to be calledSchool *Please click to select optionsE. C. Glass High SchoolHeritage High SchoolCurrent Grade *Grade 10 | SophomoreGrade 11 | JuniorGrade 12 | SeniorStudent date of birth *Student's email address *Student's phone number * OrientationThe Virginia Center for Inclusive Communities is pleased to offer an optional Orientation Session for parents/guardians and students in preparation for the Project Inclusion program. This session takes place on October 18, 2022 from 5:45 - 6:45 PM via Zoom. Please check a box below to indicate whether or not you plan to attend the Orientation Session. Your school sponsor will send a Zoom link to those who are interested in attending.Please confirm the student or parent/guardian's attendance at orientation: *YesNo Demographic Information Demographic InformationPlease provide the following student demographic information.*This information will be used to ensure that we have as diverse a community as possible. Only VCIC and Project Inclusion staff members see your responses*Gender *Religious IdentityRacial/Ethnic Background (check all that apply) *African-American/Black/CaribbeanAmerican Indian/Native AmericanAsian/Asian-AmericanLatino(a)(x)/HispanicMiddle EasternWhite/European AmericanOther IdentityIs there any other information about your identity that you would like to share (i.e. ability status, languages spoken, national origin, etc.) Would you like a phone call to discuss any aspect of your identity in advance of the Project Inclusion session so that we can best support your experience? *YesNoEmergency ContactsParent/Guardian InformationParent/Guardian Full Name *Email *Daytime Phone *Cell Phone *Language spoken at homeEmergency Contact #1 Full Name *Emergency Contact #1 Phone *Emergency Contact #1 Relationship to Participant *Emergency Contact #2 Full Name *Emergency Contact #2 Phone *Emergency Contact #2 Relationship to Participant * Health History and Medical Release Health History and Medical Release This information is gathered to assist in identifying appropriate care for the participant. All medical information is confidential. This form must be completed by the parent(s)/guardian of minors. Please make sure that you provide detailed and accurate information so that the on-site medical professional is aware of your child’s needs.Does this participant have any medical limitations that will restrict participation in program activities? *YesNoIf yes, please explainHas the student been injured and needed medical treatment within the last year? *YesNoIf yes, please explainIs the student presently undergoing professional counseling or therapy? *YesNoIf yes, please explainPlease list any allergies the student may have. (food, medicine, etc.)Describe reaction and management to the reaction belowIs the participant covered by family medical/hospital insurance? *YesNoIf YES, please share the following information:1. Insurance carrier/plan name 2. Group 3. Insurance company address 4. Name of policy holder 5. Policy holder's relationship to participant 6. Social security # of policy holder or insurance ID #Please indicate specific dietary restrictions for the studentNo red meatNo poultryNo porkNo seafoodNo eggsNo dairy productsN/APlease list any additional dietary restrictions for the studentDoes this participant take medications on a routine basis? *Please list all medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire duration of the program. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, dosage, and frequency of administration. YesNoWill the applicant be taking any prescribed medication during the program? *YesNoIf YES, please provide the following information including the name of the medicine, the dosage, and times taken each day:Does the applicant have any of the following medical conditions? (check all that apply)AllergiesAsthmaConvulsive DisordersDiabetes MellitusEpilepsyHeart ProblemHepatitis HIV Positive Muscular-Skeletal DisorderNeurological DisorderOtitis MediaSkin Infection Pulmonary Disorders Please list any other issues the medical staff should be aware of belowI give permission for the Project Inclusion staff to administer the following over-the-counter medications to my child if requested (please check all that apply):Anti-Itch SprayBenadrylMotrin (Ibuprofen)Antibiotic CreamMaaloxPepto-BismolTylenolParent /guardian must sign this emergency release agreement. If for religious reasons you cannot sign this document, contact VCIC for a legal waiver, which must be signed for attendance: *This health history is correct and complete as far as I know, and the person herein described has permission to engage in program activities except as noted. In the event of an accident or illness that requires emergency medical care, I hereby give permission to the attending (licensed) medical personnel to order such medical attention as may be deemed necessary for the health and safety of my child (or the person of whom I am legal guardian). In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Director to secure and administer treatment, including hospitalization, for the person named above. The medical information above is complete and accurate to the best of my knowledge.By checking this box, I acknowledge and agree to the above section, and confirm that the participant has also read and fully understood their agreement.I cannot sign this agreement and will contact VCIC for a legal waiverParticipant's Name *Date *Participant's Signature *Reset SignatureSignature is required.Parent/Guardian's Name *Date *Parent/Guardian's Signature *Reset SignatureSignature is required.Communication and Mailing Communication and MailingThis section should be filled out by a parent or guardian.Mailing Address *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeOptional Text MessagingTo help us send reminders and communicate quickly with participants, VCIC is establishing an optional text messaging group through Remind. If you would like to sign up the participant, please provide the best cell phone number to reach them.By checking this box, I agree to have my child/the child in my care receive text messages from VCIC staff regarding the Project Inclusion program. Standard messaging rates may apply. Phone Number of Participant to Receive TextsAfter Project Inclusion, a contact list is distributed to all participants and staff. Please check one box below: *I do grant permission for my/ my child’s address, phone number, and email address to be distributed to other Project Inclusion participants and staffI do NOT grant permission for my/ my child’s address, phone number, and email address to be distributed to other Project Inclusion participants and staff PermissionsParticipants are asked to complete a series of written evaluations that assess their views on human relations issues and the Project Inclusion program during and after the program. Please check one box below: *Student’s responses will be associated with an ID number for tracking group progress throughout the program year. The number will not be attached to my child, so responses will only be reported as group outcomes.I do grant permission for my child to complete evaluation questionnairesI do NOT grant permission for my child to complete evaluation questionnairesPlease read the following statement and check one box below: *I understand that I/my child, alone or with other participants and/or Virginia Center for Inclusive Communities (“Inclusive Communities”) staff, volunteers, or representatives, may be photographed, recorded on film, audio tape, videocassette, or other visual and sound, computerized, telephonic, voice-mail or tape media (“photographs and/or sound/image recordings”) by Inclusive Communities and/or others approved by Inclusive Communities. I hereby consent to the foregoing and grant permission, without reservation, to Inclusive Communities and/or those approved by Inclusive Communities to generate, prepare, advertise, describe, and/or publicize Inclusive Communities and its work, good will, public education, and/or fundraising activities, disseminate, otherwise use and comment upon the photographs and/or sound/image recordings as they may determine, without review by me/my child and without financial or other obligation of any nature to me/my child. I consent that I/my child may be identified by name, age, and place of residence or otherwise, as Inclusive Communities and/or those approved by Inclusive Communities may determine. I release Inclusive Communities, its officers, volunteers, agents, employees, licensees, and assigns from all claims that I/my child may have, or might have, for any cause of action arising out of the taking and/or use of the photographs and/or sound/image recordings as set forth herein. I understand that a full group picture will be taken by Inclusive Communities and provided to all program participants no matter which box is checked below. This consent and release shall continue in effect, without a limitation of time. I do consent and agree to the photo release terms mentioned aboveI do NOT consent and agree to the photo release terms mentioned aboveParticipant AgreementThis section should be filled out by the participant. I agree to be present for the entire Project Inclusion session, from beginning to end. I will be on time for all Project Inclusion sessions. I will remain within the Project Inclusion site boundaries at all times unless accompanied by a staff member in an emergency. I will not bring any weapons, laser pointers, or other prohibited material to Project Inclusion. I will not bring or use any drugs at the program except medication detailed in the medical information section of this application. I will turn in all medication to the designated person at Project Inclusion in original containers upon arrival. I will not engage in sexual activity at Project Inclusion. I agree to not enter the living quarters of members of another gender at any time. I will attend and be on time for all sessions. I will pay for any facility damage for which I am responsible. I will wear my nametag at all times. I understand that cell phone usage will be prohibited during program sessions. The presence or use of cell phones during program sessions will result in the phone being confiscated and held until the end of the program day. I understand that violating any of these rules can result in immediate dismissal from Project Inclusion at the discretion of a Director. If I am dismissed, my parent/guardian will be called to pick me up from the facility. To the best of my ability, I will join in the spirit of Project Inclusion at all times. Acknowledgment *By checking this box, I, the participant, acknowledge and agree to the above section. Participant Name *Participant's Signature *Reset SignatureSignature is required. Parent / Guardian Consent I understand that my child will be attending Project Inclusion from November 16-19, 2022 at the W. E. Skelton 4-H Educational Center. I understand that my child’s high school will provide transportation to and from the program and will provide adult supervision during the program. I understand that Project Inclusion is an intensive human relations program that deals with mature subject matters. I understand that workshop topics may include values clarification, self-esteem, stereotypes, prejudice, interpersonal communication, racial identity, racism, sexism, homophobia, classism, family issues, and more. I understand that youth who participate in Project Inclusion activities and discussions often find it to be an emotional experience. Throughout the week, students may experience confusion, anger, joy, sadness, frustration, hope and more as they learn. I assure you that my child has no known mental or emotional disorders or sensitivities that would interfere with her/his participation and that she/he is capable of handling the subject matter and emotional nature of this program. I understand that although the Virginia Center for Inclusive Communities (“Inclusive Communities”) has taken precautions to provide proper organization, supervision, instruction, and equipment for each activity, it is impossible for Inclusive Communities 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 Trustees of Inclusive Communities, and/or its employees, agents, lessors, volunteers, or lessors including those claims which may arise from the negligence of Inclusive Communities, its Board of Trustees; and/or its employees, agents, lessors or volunteers. If the Project Inclusion director must send my child home for any reason, I agree to pick up my child within four hours of the director's call (unless other arrangements are made with the director.) I understand that I may be called at any time of the night or day to arrange for my child's transportation home and that I will be responsible for all costs associated with such transportation. If my child's medical information should change prior to the program, I will notify the Virginia Center for Inclusive Communities of any new conditions, medications, limitations, etc. I have read and understand all the provided information in this form. Acknowledgment *By checking this box, I acknowledge and agree to the above section, and confirm that the participant has also read and fully understood their agreement.Parent / Guardian Name *Date *Signature *Reset SignatureSignature is required.Submit
