Registration Form

To complete the registration process, please fill in the information below and click the Send button.
First Name:           Middle Initial:       Last Name: 
  
Address:          

City:                 

State:                               Zip Code:        

Home Phone:                    Work Phone:         

Cell Phone:                        Email:                     

Conference Affiliation:      

Title/Position:    Parish Nurse:   

I like to be called: 

Please specify CEUs you are requesting:

Nursing:                         Pastoral Care:                    Other: 

I would like to share a room with: 

I give my permission to add my name and information to the participant list.   
                                                                                                                                   
Special Needs:
(Indicate your special needs here, i.e. Ambulatory, Visual, Hearing, Diet, etc. If "none" list none.)

 


SESSION REGISTRATION

(Please specify your 1st, 2nd, and 3rd choice for each of the workshops.)

MONDAY
  "Creating a Resource Library"
  "Networking Partnering with Other Agencies"
  "How To Develop the Leadership for Conference Wellness"

TUESDAY - Session I
  "Prayer Beads"
  "Gift Boxes To Go"

TUESDAY - Session II
   "Tibetan Bowls"
  "Tai Chi"

TUESDAY - Session III
   "HIV/AIDS and the Church: A Call to Action"
  "Changing A Cultural Perspective: Illness vs. Wellness"
  "Change? Who, Me? Issues of Behavior Changes and Health"

WEDNESDAY - Session I
   "After the Diagnosis, What's Next?"
  "Exercise Your Faith: Spiritual Discipline and Wellness"

WEDNESDAY - Session II
   "Healthy Habits and Lifestyle Change"
  "Spirituality: Healing in Mind/Body"

 

To send information, click     To reset to initial values, click

Home | Registration Form

This site was updated on 04/29/2006