Connections 2022 Volunteer Registration | Virginia Center for Inclusive Communities

Overview

Connections Volunteer Facilitator Registration

Thank you for your submitting your volunteer application for the Connections Summit, scheduled for July 26, 27, and 28, 2022, made possible thanks to the financial support of Atlantic Union.

Volunteers must commit to attending the full program from 9:00am – 5:00pm each day.

As a reminder, volunteers are expected to attend both a virtual orientation session on July 14 from 6:00pm-8:00pm; and an in person training on July 25 in Hampton Roads. Full attendance at both the orientation and training will be mandatory in order to volunteer.

Volunteer registration forms are due July 1, 2022.

If you have any questions, please contact VCIC’s Educational Programs Associate Emma Cox at ecox@inclusiveVA.org.

Personal Information

CONNECTIONS VOLUNTEEER REGISTRATION

Please complete the registration by July 1, 2022.

Full Name (First, Middle, Last) *

Name I Prefer to be called *

Pronouns

Release/Consent Form

Connections Summit 2022 Release/Consent Form

After the Connections Summit, a contact list is distributed to all participants and staff. Please check one box below: *

I do grant permission for my address, phone number, and email address to be distributed to Connections participants and staff.

I do not grant permission for my address, phone number, and email address to be distributed to Connections participants and staff.

Signature *

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Signature is required.

The terms and conditions of the Virginia Center for Inclusive Communities photo/video policy are below. Please read, check one box, and sign to demonstrate your understanding and agreement: *

I understand that I, alone or with other participants and/or Virginia Center for 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 the Virginia Center for Inclusive Communities and/or others approved by said organization. I hereby consent to the foregoing and grant permission, without reservation, to the Virginia Center for Inclusive Communities and/or those approved by said organization to generate, prepare, advertise, describe, and/or publicize the Virginia Center for 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 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 the Virginia Center for Inclusive Communities and/or those approved by said organization may determine. I release the Virginia Center for Inclusive Communities, its officers, volunteers, agents, employees, licensees, and assigns from all claims that I 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 Connections participants no matter which box is checked below. This consent and release shall continue in effect, without a limitation of time. Please check one box below:

I do consent and agree to the photo release terms mentioned above.

I do not consent and agree to the photo release terms mentioned above.

Signature

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Health History & Medical Release

This information is gathered to assist in identifying appropriate care for the staff member. Please make sure that you provide detailed and accurate information so that we are aware of your needs. All medical information is confidential.

Address *

Country

City

State

Zip code

Date of Birth *

Home Language(s)

Medical Emergency Contact #1 *

Medical Emergency Contact #1 Phone *

Medical Emergency Contact #1 Relationship *

Medical Emergency Contact #2 *

Medical Emergency Contact #2 Phone *

Medical Emergency Contact #2 Relationship *

COVID-19 Vaccination Status *

We are requiring all volunteers 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. Please indicate your current vaccine status. If you do not plan to be fully vaccinated before the program, a VCIC staff member may reach out to discuss further options. We will not share your vaccination status with anyone outside of the organization.

I am fully vaccinated and will attach my verification to this form

I am partially vaccinated and plan to receive my booster by July 11

I do not plan to be fully vaccinated by the date of the program

I would prefer not to answer at this time

I have a medical exemption

Do you have physical limitation that will restrict participation in program activities? *

Yes

No

If Yes, explain:

Have you been injured and needed medical treatment within the last year? *

Yes

No

If Yes, explain:

Are you presently undergoing professional counseling or therapy? *

Yes

No

If Yes, explain:

List all known allergies (to medication, food, etc.) *

If applicable, describe reaction and management to known allergies

If Other, please explain:

Do you take medications on a routine basis? *

Yes

No

If Yes, please explain

Will you be taking any prescribed medication during the program? *

Yes

No

If yes, please provide the following information

Please share the name of medicine(s), specific times taken each day, and dosage

If other, please explain:

Are you covered by family medical/hospital insurance? *

Yes

No

If Yes, please provide the following information:

Insurance carrier/plan name, group #, name of policy holder, relationship to self, social security # of policy holder or insurance ID #

If for religious reasons you cannot sign the statement below, contact the Virginia Center for Inclusive Communities for a legal waiver, which must be signed for attendance.

This health history is correct and complete as far as I know, and I have 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 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.

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Volunteer Facilitator Agreement

I commit to being present at:

Facilitator Orientation (virtual)
- July 14 from 6:00pm-8:00pm
Facilitator Training Session (in person)
- Hampton Roads - July 25
Connections Summit
- Hampton Roads - July 26, 27, and 28, 2022

I understand that although the Virginia Center for Inclusive Communities (“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/volunteer shares the responsibility for safety during all activities and I assume that responsibility for myself. 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 I will be required to follow appropriate mask guidelines while indoors at Connections. This includes wearing a well-fitting mask that offers full coverage of my nose, mouth and chin.

I understand that volunteer facilitators may be asked to complete a series of written evaluations that assess their views on Connections after the program.

I understand that I, alone or with other participants and/or sponsor 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 the sponsor and/or others approved by sponsor.

I understand that volunteers must maintain appropriate conduct and follow clear guidelines with all minors participating in Connections. Appropriate conduct and guidelines are outlined on the "Facilitator Code of Ethics Professional Boundaries When Working with Minors" sheet.

I certify that the information provided in this application is true and complete. I authorize the sponsor to investigate the facts presented in this application and to secure any necessary information from all employers, references, academic institutions, and other organizations. I also agree to execute any additional written authorizations necessary for sponsors to obtain access to and copies of records pertaining to this information. I agree to release any person, company, or other institution from any and all cause of action that otherwise might arise from supplying sponsors with information it may request pursuant to this release.

I understand that acceptance of my offer of volunteer services to the sponsor is contingent upon receipt of satisfactory responses to any or all investigations conducted by the sponsor. I understand that any false answers or statements, or misrepresentations by omission, made by me on this application or any related document, will be sufficient for rejection of my application, or for my immediate discharge if discovered after I begin providing volunteer services. I agree to comply with all applicable policies, procedures and rules of the sponsor, and I understand that any violation may result in my immediate dismissal as a volunteer. I understand that nothing in this application, or in acceptance of my offer of volunteer services, is intended to create an employment contract between the sponsor and me.

I acknowledge that Connections may shift to a fully-virtual setting due to COVID-19 concerns.

I hereby acknowledge that I have read and understand the preceding statement *

Print Name

Signature *

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

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Signature is required.

Date *