DDD Richmond – Student Registration Form | Virginia Center for Inclusive Communities

RICHMOND DIVERSITY DIALOGUE DAY STUDENT INFORMATION & PERMISSION FORM

Student’s Full Name (First, Middle, Last) *

Name Student Prefers to be called *

School *

Please type out full name of school

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 *

Student Email *

Medical Emergency Contact Name *

Medical Emergency Contact Relationship *

Medical Emergency Contact Phone *

Dietary Restrictions (please be specific): *

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

Please provide the following student demographic information.

*This information will be used to ensure that we have as diverse a community at Diversity Dialogue Day as possible*

Gender *

Religious Identity *

Agreements

I give permission for my child to participate in the 2022 Diversity Dialogue Day conducted by the Virginia Center for Inclusive Communities on December 8 at the University of Richmond. I understand that Diversity Dialogue Day 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 Diversity Dialogue Day 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 Diversity Dialogue Day.

Parent/Guardian Printed Name *

Parent/Guardian Signature *

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

Reset Signature

Signature is required.

Date *

Optional Pre-Survey Questions

Below are some optional pre-survey questions that will help VCIC to develop curriculum that is relevant and current. These should be answered by the student based on their experiences at school. NOTE THAT NAMES WILL NOT BE TIED TO RESPONSES.

Please write the first three words that come to mind when you hear the word “stereotype”.

Please check up to three identities that you think get stereotyped most often in your school:

Below is a list of identities, as well as some examples of descriptions people use for those identities.

	Choose up to three
Ability Status (person who uses a wheelchair, person with a learning disability, etc.)
Age (old, young, etc.)
Appearance/Body Type (short, skinny, etc.)
Gender (female, male, etc.)
National Origin (Chinese, Mexican, etc.)
Race (African-American/Black, Hispanic/Latino(a), etc.)
Religion (Christian, Muslim, etc.)
Socioeconomic Status (lower income, middle income, etc.)
Sexual Orientation (gay, lesbian, etc.)

How strongly do you agree with the following statement: "I believe that I can contribute to reducing stereotypes in my school."

Choose from drop-down list