Project Inclusion Staff Registration

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Staff Information

Project Inclusion Staff Form

Please complete the form by January 19, 2023.

NOTE: You cannot save your partially completed form so please review the full form before starting to complete.
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Demographic Information

Demographic Information
Please provide the following demographic information.
*This information will be used to ensure that we have as diverse a community as possible. Only VCIC staff members see your responses*

Emergency Contacts

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. Please make sure that you provide detailed and accurate information so that the on-site medical professional is aware of your needs. Depending on health conditions in February, VCIC may require masking and other mitigation practices.
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 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.
We are requiring all staff to be fully vaccinated before the program. To be considered fully vaccinated, an individual must have received both a primary vaccine(s) and a booster at least two weeks before the program. Please indicate your current vaccine status. We will not share your vaccination status with anyone outside of the organization.
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 my health and safety. The medical information above is complete and accurate to the best of my knowledge.
Signature is required.


I understand that I, alone or with other participants and/or Virginia Center for Inclusive Communities (“VCIC”) 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 VCIC and/or others approved by VCIC. I hereby consent to the foregoing and grant permission, without reservation, to VCIC and/or those approved by VCIC to generate, prepare, advertise, describe, and/or publicize VCIC 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. I consent that I may be identified by name, age, and place of residence or otherwise, as VCIC and/or those approved by VCIC may determine. I release VCIC, 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. This consent and release shall continue in effect, without a limitation of time. I understand that a full group picture will be taken by VCIC and provided to all program participants no matter which box is checked below.
Project Inclusion Code of Ethics
  1. Staff members will maintain confidentiality at and after the Project Inclusion experience (except for mandatory reporting, such as abuse or when individual is a danger to self or others).
  2. Staff members will exhibit language that is consistent with the Project Inclusion mission (no disrespectful comments related to ability, body type, class, gender, race, religion, sexual orientation, etc.).
  3. Staff members will obey the law in all aspects of interaction with the program, participants, staff members, and VCIC staff.
  4. Staff members will not abuse participants in any way, including (but not limited to) the following:
    • Physical abuse: hitting, spanking, shaking, slapping, unnecessary restraints
    • Verbal abuse: degrading, threatening, cursing
    • Sexual abuse: inappropriate touching, exposing oneself, sexually oriented conversations
    • Mental abuse: shaming, humiliation, cruelty
    • Neglect: withholding food, water, shelter
  5. Staff members will have no physical (sexual, romantic, inappropriate touching) relationships with other volunteers at the Project Inclusion program or with participants at or after the Project Inclusion program.
  6. Staff members will avoid any favoritism and will treat everyone equally and respectfully at all times.
  7. Staff members will adhere to uniform standards of displaying affection as outlined by VCIC.
  8. Staff members will adhere to uniform standards of appropriate verbal interactions as outlined by VCIC.
  9. Staff members will not be alone with minors in meeting spaces. There should be staff members of different genders present when you are meeting with an individual minor.
  10. Staff members will model respect for program facilities.
  11. Staff members will not use or be under the influence of alcohol or illegal drugs in the presence of participants.
  12. Staff members will not have sexually oriented materials, including printed or online pornography, on the program site.
  13. Staff members will not engage in inappropriate electronic communication with participants, during or after the program.
  14. Staff members may maintain relationships with the participants after the Project Inclusion program if the outreach is student-initiated. If a student reaches out, staff members must notify VCIC immediately and a VCIC staff member should be copied on all future correspondence. All communication should be in support of positive, supportive, and healthy mentoring relationships.
  15. Staff members will abide by the decisions of the co-directors and Virginia Center for Inclusive Communities before, during, and after the program.
  16. Staff members are prohibited from making use of or reproducing Project Inclusion curricula or ancillary material for any purpose other than rendering service to the Virginia Center for Inclusive Communities.
Signature is required.

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