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Click here for a printable Form
The Black Church HIV/AIDS Institute Registration & Pre-Evaluation Form 2003
REGISTRATION FORM: For Church Members Only!
Your Information
* required fields
Salutation (select one):
*First Name:
*Last Name:
*Mailing Address:
*City:
*State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Nova Scotia Newfoundland NW Territories Ontario Quebec Prince Edward Island Saskatchewan Yukon Non US
*Zip:
*Day Phone:
*Email:
Fax:
Evening Phone:
Church Information
*Name of Church:
*Name of Pastor:
*Church Mailing Address:
*Phone:
Email:
Web site:
Church denomination:
--Select Denomination-- African Methodist Episcopal African Methodist Episcopal Zion African Orthodox Church American Baptist Churches USA Anglican Catholic Christian Methodist Episcopal Church of God Church of God In Christ Congregational Disciples of Christ Episcopal Evangelical Lutheran Church Full Gospel Holiness Jehovah's Witness Mennonite Metropolitan Community Churches National Baptist Convention of America National Baptist Convention, USA Pentecostal Presbyterian Church (USA) Progressive National Baptist Convention Reformed Church in America Seventh Day Adventist United Church of Christ United Methodist United Methodist Presbyterian Episcopal Unity Church Unity Fellowship Church Universal Foundation for Better Living Other
Approximate number of church members:
1. Is this your first time attending The Black Church HIV/AIDS Institute? Yes No
2. How many times have you attended the The Black Church HIV/AIDS Institute?
3. Please list name and date of other The Balm In Gilead training sessions, which you have attended.
4. Does your church have a HIV/AIDS Ministry? Yes No
5. What type(s) of HIV/AIDS ministry activities is your church currently involved with? (Please check all that apply).
Harm Reduction
HIV Children's Services
HIV Hospice
HIV Housing
HIV/AIDS Education
HIV Prevention
HIV Community Planning
HIV Testing and Counseling
HIV Youth outreach
Prison Outreach
Needle exchange
Substance Abuse
HIV in Africa
Volunteer Program for Persons Living with HIV/AIDS
Other (Please specify)
6. What role do you play in your church's HIV/AIDS ministry activities?
7. What do you hope to gain from attending The Black Church HIV/AIDS Institute 2003?
8. Would your church be interested in obtaining a HIV/AIDS curriculum for use in the Sunday school? Yes No
9. What is the current size of your Sunday school?
10. Please rate your knowledge level in each of the following areas (Place the number that best corresponds to what you know next to each item):
A lot
A Fair Amount
Some
A Little
None
(1)
(2)
(3)
(4)
(5)
Policy issues relevant to Blacks and HIV/AIDS
HIV/AIDS information (e.g., definition, transmission, prevention measures)
Establishing a HIV/AIDS Ministry
Establishing faith-based HIV testing program
Grant writing to fund faith-based HIV/AIDS programs
HIV prevention community planning
Teaching HIV/AIDS within the context of ministry
Technical Assistance
11. What skills or information would you need to conduct more effective programs?
Communication
12. What newspapers do people in your area read most?
13. What is the most popular local radio station?
14. How many times have you visited The Balm In Gilead Web site?
Never 1- 5 times regularly (at least once a week)
15. Are you a member of The Balm In Gilead web site? Yes No
16. How many times in the past month have you used the resources (links to information on HIV/AIDS web site) on The Balm In Gilead web site?
17. How did you hear about the The Black Church HIV/AIDS Institute 2003?
18. Please check all church auxiliaries to which you belong:
(a) Pastor
(f) Prison Ministry
(k) Church School
(o) Youth Ministry
(b) Homeless
(g)Ministry
(l) Young Adult
(p) Deacon
(c) AIDS Ministry
(h) Nurses' Unit
(m) Usher
(q) Missionary
(d) Substance Abuse
(i) Health Ministry
(n) Assistant Pastor
(r) Trustee
(e) Choir
(j) Other (Please Specify)
CLASS REGISTRATION: YOU MUST CHOOSE!
Seminars: Wednesday, May 28 3:30pm - 5:30pm Choose One How HIV Works in the Body HIV Positive Adolescents: Addressing Their Issues HIV Positive Seniors: Addressing the Issues! Update on Clinical Trials, Vaccines and the Involvement of Black People Hepatitis C - The Silent Epidemic in the African American Community How the Church Can Influence and Shape Effective Parenting Skills
CIRCLES OF DEVINE LOVE! : Thursday, May 29 1:30pm - 3:00pm Choose One Pastoral Care for Pastors and Ministers Only A Moment of Truth for Sisters Only Brothers Coming Together to Talk Real!
Skills Building Workshops: Thursday, May 29 3:15pm - 5:30pm Choose One Tools for Prophetic Preaching of HIV Developing an Effective HIV/AIDS Ministry Fundamentals of HIV Testing and Counseling Teaching Teens Survival Techniques Fundamentals of Teaching Abstinence Only Overcoming Stigmas Associated with AIDS in African American Communities
Skills Building Workshops: Friday, May 30 10:30am - 12:30pm Choose One Black Churches Taking the Lead: Strategies for HIV/AIDS Mobilization and Collaboration Writing for Government Grants and Foundation Support Tools for Developing a Faith-Based HIV Clinic The Role of Faith Leaders in Community Planning Developing Effective Faith-Based Substance Abuse Treatment Programs
CONFERENCE REGISTRATION
Before May 20: $275.00, After May 20 and On-Site: $300.00
Full Conference Package Before May 20th: $275.00 (After May 20th and on site: $300.00) - or -
$ (Insert cost)
Daily Conference Package $125.00 (per day) Select Date(s): 05/28/2003 05/29/2003 05/30/2003
GRAND TOTAL Amount Submitted to The Balm In Gilead
Mastercard Visa American Express Discover
Card Number: Expiration Date: Name as it appears on card:
Phone: (evening)
.............................................................................................................................................................................................. Greetings | Goals of the Institute and Who Should Attend? | Registration Information | Conference Schedule AIDS Facts | Denominational Support
