The Balm In Gilead: Programs

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Programs

The Black Church Week of Prayer

Our Church Lights The Way: HIV Testing Campaign

Faith-Based HIV/AIDS National Technical Assistance Center

Africa HIV/AIDS Faith Initiative

Denominational Leadership Initiative

Black Church HIV/AIDS Training Institute

The ISIS Project

Certified Service Partners

The Black Church HIV/AIDS Network

Resources

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THE BLACK CHURCH INSTITUTE FOR HIV/AIDS
AND OTHER HEALTH DISPARITIES
REGISTRATION & PRE-EVALUATION FORM 2006

Click here for
a printable Form

Your Information
* required fields
Salutation (select one):	Rev. Mr. Mrs. Ms. Miss Dr.
*First Name:
*Last Name:
*Mailing Address:
*City:
*State:
*Zip:
*Day Phone:
*Email:
Fax:
Evening Phone:

Church Information

*Name of Church:
*Name of Pastor:
*Church Mailing Address:
*City:
*State:
*Zip:
*Phone:
Email:
Web site:
Church denomination:
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. Does your church have a health ministry that does not include HIV/AIDS?

7. What types of health ministry activities is your church involved in?

Cardiovascular
Diabetes
Cervical Cancer
Hypertension
Fitness
Hepatitis C
Other (Please specify)

8. What role do you play in your church�s HIV/AIDS or health ministry activities?

9. What do you hope to gain from attending THE BLACK CHURCH INSTITUTE FOR HIV/AIDS AND OTHER HEALTH DISPARITIES 2006?

10. Would your church be interested in obtaining a HIV/AIDS curriculum for use in the Sunday school?
Yes No

11. What is the current size of your Church school?

12. 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

13. What skills or information would you need to conduct more effective programs?

Communication

14. What is the most popular local radio station?

15. How many times have you visited The Balm In Gilead Web site?

Never 1- 5 times regularly (at least once a week)

16. Is your church a member of The Balm In Gilead’s Black Church Network? Yes No

17. 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?

18. How did you hear about the The Black Church HIV/AIDS Institute 2006?

19. 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!

WORKSHOPS I: Successful African American Faith-Based HIV/AIDS Program Models
Wednesday, October 25
Choose One

HIV Testing Models: Tools for Getting Started
HIV Clinical Models: Tools for Getting Started
A Comprehensive Service Model: From HIV Testing to Treatment Adherence
Tools for Developing A Successful HIV Ministry
Tools for Addressing HIV Within Your Prison Ministry
Drug Treatment Models: (Running a Successful Program)

WORKSHOPS II! : Thursday, October 26
Choose One

Key to Survival! Treatment, Education and Adherence
The Emerging Epidemic! Hepatitis C
Black Women, HPV and Cervical Cancer: What EVERY Woman Must Know!
Tools for Effective Abstinence-Based HIV/AIDS Programs
The Fundamental of HIV Science
No More Dialysis! Renal Disease Prevention, Treatment and Care

WORKSHOPS III: Thursday, October 26
Choose One

A Church School Curriculum for HIV/AIDS
How to Develop Effective Partnerships With Your Local Health Department
Stroke! Prevention, Treatment & Care
The Role of Public Policy and Faith-Based Programs
The Black Church and Sexuality

Workshops IV: Thursday, October 26
Choose One

Developing An Effective Youth Ministry
Tools for Developing Effective Health Service Programs for Black Women
Black Gay Men and HIV: (An Intimate Discussion on Survival)
Building Faith-Based Partnerships for Increased Access to and Utilization of HIV Prevention Services
Spirituality, Healing and Wholeness
The Fundamentals of Sexuality Training for Black Pastors and Congregations

Seminars: Friday, October 27
Choose One

For Pastors and Ministers Only
Tools for Evaluating Faith-Based Programs
Fundamentals of Grant Writing
Skill Building: Program Planning, Design and Implemention
Black Women Getting on Track: A Successful Faith-Based Obesity Program

CONFERENCE REGISTRATION

Before October 13: $325.00, After October 13 and On-Site: $375.00

Full Conference Package Before October 13h: $325.00 On-Site: $375.00 - or -	$ (Insert cost)
Daily Conference Package $115.00 (per day) Select Date(s): 10/24/2006 10/25/2006 10/26/2006 10/27/2006	$ (Insert cost)
Exhibit Booth Church HIV/AIDS or Health Program - $100 Community Based Organization - $250 Other - $500	$ (Insert cost)
GRAND TOTAL Amount Submitted to The Balm In Gilead	$ (Insert cost)

*Payment Options
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Card Number: Expiration Date: Name as it appears on card: Card ID Number: Where is my Card ID Number? *Required for Visa and MasterCard.
Enter Complete Billing Information
*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Phone:
Phone: (evening)
*Email:	(MUST BE A VALID EMAIL ADDRESS)

Print Form

Mail to:
The Balm In Gilead Inc.
130 West 42nd Street, Suite 704
New York, NY, USA 10036
Tele: (212) 730-7381
(888) 225-6243
Fax: (212) 730-2551

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