Youth Workshop Participants Ages 11—19 yrs. old
Union of Black Episcopalians New York Chapter
Must complete Authorization Form below
Youth Authorization Form _________
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___________
Child’s Age
Sex
D.O.B.
Northeast Regional Conference
_______________________ Guardian’s Phone Number
Loving Our Neighbors As Ourselves… Living In A Polarized Society
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Parent / Guardian’s Name
PARENT’S AUTHORIZATION I authorize the Conference Registrars to secure medical or surgical care for my child, and to take such action and give such consent on my behalf as he/she determines, based upon the medical advice given, to be in the best interests of my child. (Please list any medical problems or allergies below.) I also give my permission for my son/daughter to be transported to and from events during the conference.
Date
_________________________________________ Parent / Guardian’s Signature
Medical Problems/Allergies: _____________________________ ______________________________________________________ ______________________________________________________
Union of Black Episcopalians New York Chapter P.O. Box 861 Bronx, New York 10473
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April 26, 2014 Church of the Intercession 550 West 155th Street, NY, NY 10032 The Rev. Rhonda Rubinson, Priest-in-Charge Earl K.D. Francis, Chapter President Louise Hannibal-Boyce, Vice-President & Conference Chair The Rev. Canon Dr. Lynn A. Collins, NE Regional Director
Northeast Regional Conference Saturday April 26, 2014 Church of the Intercession 550 West 155th Street NY, NY 10032 Between Amsterdam and Broadway
“Loving Our Neighbors As Ourselves... Living In A Polarized Society”
Registration Form
Adult Workshops (Choose 2)
The Union of Black Episcopalians
Print/Type Clearly
A. The Black Presence in the Bible Onleilove Alston, M. Div, MSW, Community Organizer, Speaker & Writer
_________________________________________________________________ Last Name
First Name
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B. Hate Cannot Drive Out Hate; Only Love Can Do That The Rev. Mark Bozzuti-Jones, Director for Pastoral Care & Community, Trinity Church Wall Street C. The Importance of a Support Network—I Am My Brothers’/Sisters’ Keeper Jacqueline D. McLeod, MPH, Executive Director, Healing Communities Network (HCN)
Street and/or Mailing Address ________________________________________________________________ City/State/Zip ______________________________________________________________ Phone Number with Area Code _______________________
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Diocese
Chapter
Any Special Dietary Needs __________________________________________
Agenda
Youth Workshop (Ages 11 - 19)
8:00 - 8:45 am
Registration / Breakfast
8:50 - 9:20 am
Morning Prayer /Welcome /
Loving Our Neighbors As Ourselves: A View on Gun Violence, Black on Black Crime and How to Love One Another Rev. Sharon L. Bierria, Associate Pastor, The Triumphant Agape House, Community Activist
Announcements 9:30 - 10:20 am
Workshops A,B,C
10:30 - 11:20 am
Workshops A,B,C
11:30 - 12 noon
Keynote Address
12:00 - 12:45 pm
Lunch
12:50 - 1:30 pm
Business Meeting
1:30 -
2:00
Pickup Choir
2:00 -
3:00
Eucharist and Dismissal
*************************************************************** Youth Conference
9:30 - 11:30 am
Youth Business Meeting
12:50 - 1:30 pm
*
Children under 11 are welcome to attend the Conference but they must remain with a parent or guardian.
Please Select Adult Workshops in order of preference (A, B, or C ): A ________
B ________
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_______________________________________________
Date
Applicant’s Signature
Registration Fee: $45.00 Adults / $25.00 Youth Make checks payable to: UBE New York Chapter Adult / Youth
For questions regarding ground transportation, hotel accommodations, or additional information, please contact: Mrs. Mabel Wernham 917-751-5630
[email protected] C ________
(Please circle one)
For youth: Please complete the YOUTH AUTHORIZATION FORM on the reverse side
Please mail check and completed registration form by March 21, 2014 to: New York Chapter Union of Black Episcopalians P.O. Box 861 Bronx, New York 10473