Please type out full name of school
email address of school contact / educator that asked you to submit this form
(Note that VCIC will do our best to meet all requests.)
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*
  • I give permission for my child to participate in the 2023 Diversity Dialogue Day conducted by the Virginia Center for Inclusive Communities on March 8 at the Old Dominion University Webb Center. 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.
By writing and signing my name, I hereby acknowledge that I have read and understand the preceding agreements.
Sign on the line with mouse cursor or with your finger on a touchscreen.

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.

Below is a list of identities, as well as some examples of descriptions people use for those identities.
Choose from drop-down list

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