VIBE Information

Please complete the form by July 9, 2021.

In order for selected students to attend the program, they must also have a parent or guardian sign a permission form (in addition to signature below). Permission forms will be sent out after the information form is received, and due by July 15.

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

Student Information

Please complete the following section with the student's name and contact information

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

Name I Prefer to be called *

Address *

Country

City

State

Zip code

Email *

Phone *

Grade in Fall of 2021 *

Grade 10 | Sophomore

Grade 11 | Junior

Grade 12 | Senior

School that you will be attending in the Fall of 2021 *

Please write the full school name (ex: Virginia High School) without abbreviation (ex: VHS)

Are any particular accommodations needed for the student to be able to join by video? *

Accommodation requests will only be used to help VCIC plan a program that is as accessible as possible

Yes

No

If yes, please explain

Please provide the following demographic information.

*This information will be used to ensure that we have as diverse a community as possible.*

Gender

Religious Identity

Is there any other information about your identity that you would like to share (i.e. ability status, languages spoken, national origin, etc.)

Short Answer Questions

Please respond to the following three questions. You can choose how to respond. Some options include: writing a short response using the text box below (no more than 500 words), writing a poem or song, or creating a visual art piece. (If you record a song or create visual art, please submit it by uploading the file and use the text box below to share a few brief written sentences explaining how the piece relates to the three prompts.) This is not a graded assignment, so please write in a way that is most comfortable to you. We are wanting to learn about you and will not be judging responses based on English proficiency or spelling and grammar. Your submission must be your own original content and has to be created specifically for your VIBE information form.

Explain why you are interested in attending VIBE, and what you hope to gain from the program.
What are you currently involved in at school or in your community?
From your perspective, what are the biggest issues facing your school or community?

Short Response Area

500 Word Limit

File Upload

Use this link to upload any visual art/audio/video files here, if you chose to do so. If your file is too large to upload, please email to ecox@inclusiveVA.org.

Acknowledgment *

By checking this box, I verify that I have not attended a past Connections Institution or Project Inclusion retreat.

By checking this box, I acknowledge that I am submitting my information to VCIC’s Virtual Institute for Belonging and Equity.

Applicant Signature *

Reset Signature

Signature is required.

Parent / Guardian Consent

Parent / Guardian Name *

Parent / Guardian Phone *

Parent / Guardian Email *

Acknowledgment *

By checking this box, I acknowledge that my child is submitting their information to VCIC’s Virtual Institute for Belonging and Equity.

Signature *