In Community With ACPE's Annual Conference Registration Form
In Community With ACPE's Annual Conference Registration Form
In Community With ACPE's Annual Conference Registration Form
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REM’s 25 th<br />
<strong>Annual</strong> <strong>In</strong>vitational<br />
in community with ACPE’s <strong>Annual</strong> <strong>Conference</strong><br />
<strong>Registration</strong> <strong>Form</strong><br />
Be sure to review and complete all sections of this form.<br />
Last Name First Name Middle Name<br />
Preferred First Name on Badge ACPE Member: Yes No ACPE Region<br />
Mailing Address<br />
City State Zip Country<br />
Phone<br />
Email<br />
If you serve in any National Leadership role please indicate:<br />
Vegetarian Yes No Food Allergies Yes No (please specify)<br />
Kosher Yes No<br />
ADA Needs Yes No Emergency Contact Emergency Phone<br />
REGISTRATION & TICKET FEES<br />
<strong>Registration</strong><br />
Members of ACPE may register at www.acpe.edu. All others may complete the enclosed registration form and fax it to 404-320-0849, or mail it to 1549<br />
Clairmont Road, Suite 103, Decatur GA 30033. Please read and complete the entire form carefully as there are many options for your consideration.<br />
Payment must be made at time of registration – no forms will be accepted without payment. Admission Policy: Only registered individuals having a name<br />
badge may attend educational sessions. <strong>In</strong>dividual tickets are available for other events not included in your <strong>Registration</strong> category; tickets will be required<br />
for entry to some events. Also, remember to register or purchase tickets for a participating guest. <strong>Registration</strong>s will not be accepted by phone. The Early<br />
Bird <strong>Registration</strong> Deadline is December 16, 2011. Pre-registration ends January 20 th – we invite you to register on site after this date!<br />
Cancellation Policy<br />
All cancellation requests must be submitted in writing, fax it to 404-320-0849, or mail it to 1549 Clairmont Road, Suite 103, Decatur GA 30033. All refunds<br />
will be processed within 30 days after the conference. All requests received by December 16, 2011 are eligible to receive a refund of registration and meal<br />
ticket fees, minus a $60 processing fee. Written cancellations received after this date are eligible to receive a refund of registration fees only (no meals<br />
refunded), minus a $60 processing fee. Cancellations received as of January 6, 2012, are not eligible to receive any refund. However, the courtesy of your<br />
notice will be greatly appreciated.<br />
ADA Compliance<br />
The Sheraton National Hotel is ADA Compliant. Please be sure to let your reservationist know if you have specific guest room requirements. As well, if you will let us know<br />
what assistance you need on this form, or in an attached note, ACPE will also do our best to accommodate you.<br />
Part A: <strong>In</strong>clusive <strong>Registration</strong> OR One-Day <strong>Registration</strong>s<br />
Part B: Additional Tickets and Events<br />
Part C: Late <strong>Registration</strong> Fee, after December 16, 2011<br />
PAYMENT INFORMATION<br />
$_____________<br />
$_____________<br />
$_____________<br />
____________________________________________________________________________________________________________________________________________<br />
Total <strong>Registration</strong> and Ticket Fees Due to ACPE/REM<br />
$_____________<br />
<strong>Registration</strong>s, Donations and Fees may be paid by credit card or by check.<br />
If multiple forms of payment are being used (business paying for some charges & personal payment for other charges), please record each one below.<br />
MC_____ Visa_____ AmEx_____Discover_____ $________________<br />
Card #_________________________________Exp. Date___________<br />
Cardholder Name ___________________________________________<br />
MC_____ Visa_____ AmEx_____Discover_____ $________________<br />
Card #_________________________________Exp. Date___________<br />
Cardholder Name ___________________________________________<br />
Check payable to ACPE/REM, Check #________<br />
Check Amount $_______________<br />
Check payable to ACPE/REM, Check #________<br />
Check Amount $_______________<br />
Page 1 of 4
Part A: All <strong>In</strong>clusive Package<br />
ACPE Supervisors, Associate Supervisors, Candidates, Clinical Members, and Other Pastoral Care Professionals $425.00 _____<br />
CPE and Seminary Students; Retired Supervisors, Retired Members, Spouses / Significant Others $195.00 _____<br />
The following events are all included in your INCLUSIVE REGISTRATION PACKAGE, a ticket will be required for entry to some of these events.<br />
It is important that you indicate below which of these events that you WILL / WILL NOT attend.<br />
There are additional events and guest tickets available for participation on the last page of this registration document.<br />
Wednesday, February 8 th<br />
_____ACPE Presidential Dinner in community with REM’s 25 th Anniversary Celebration<br />
Thursday, February 9 th<br />
_____<strong>In</strong>terfaith Service<br />
_____Plenary #1 Dr. Emmanuel Lartey<br />
_____Discussion Group<br />
_____Workshop Selections - Please select your THREE choices, in order of preference, indicating 1 st , 2 nd , or 3 rd . Space is limited but we will do our best to accommodate your 1 st choice.<br />
___T1. Teach Research in CPE Residency Programs<br />
___T5. Coming Out ~ Coming <strong>In</strong>: Pastoral Care with Sexual Minorities<br />
___T2. Use of Self in CPE Supervision<br />
___T6. Supervising Wounded Healers: Through Trauma Psychology & Culturally Sensitive Care<br />
___T3. Silent Cry: <strong>In</strong> Search of Harmony on Gold Mountain<br />
___T7. Pastoral Care to Spiritual Care: Embracing Our Future<br />
– The Yin-Yang Way of Pastoral Care ___T8. A Black Woman’s Journey of <strong>In</strong>terdependence: How African Spirituality and Womanist<br />
___T4. Embracing the Present: Mindfulness Meditation as<br />
Theology Have Impacted My <strong>In</strong>tercultural Pastoral Care<br />
Self-Care for Pastoral Caregivers<br />
___T9. Navigating the Certification Process<br />
_____ACPE Regional Meetings<br />
___Northeast Region: Maine, Massachusetts, New Hampshire, Rhode Island, Vermont ___North Central Region: Illinois (Northern), Iowa, Michigan (Upper Penninsula) Minnesota, North Dakota, South Dakota, Wisconsin<br />
___Eastern Region: Connecticut, Delaware, New Jersey, New York, Pennsylvania ___South Central Region: Colorado, Illinois (South), Kansas, Missouri, Nebraska, Wyoming<br />
___Mid-Atlantic Region: District of Columbia, Maryland, No. Carolina, Virginia, W. Virginia ___Southwest Region: Arkansas, Louisiana, New Mexico, Oklahoma, Texas<br />
___Southeast Region: Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee ___Pacific Region: Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington<br />
___East Central Region: <strong>In</strong>diana, Kentucky, Michigan (except Upper Peninsula), Ohio, Pennsylvania (Western)<br />
_____REM <strong>In</strong>vitational 25 th Anniversary Celebration at Howard University (transportation is included, pre-registration is required)<br />
Friday, February 10 th<br />
_____Denomination / Faith Group Breakfasts – Please indicate which breakfast you will be attending. Spouses are welcome at this event, please indicate the number attending.<br />
While most of these breakfasts are sponsored by the respective faith tradition, some may require an additional fee.<br />
___Alliance of Baptist ___ Lutheran ___ Seventh-Day Adventist<br />
___American Baptist ___ Pentecostal/Charismatic/Assemblies of God ___ Southern Baptist<br />
___Baptist General Convention of Texas ___ Presbyterian-USA ___ United Church of Christ<br />
___Cooperative Baptist Fellowship ___ Reformed Church in America/Christian Reform ___ United Methodist<br />
___ Roman Catholic<br />
See ADDITIONAL TICKETS and EVENTS (page 4) to register for the Christian Church (Disciples of Christ), Episcopal, or Unitarian Universalists breakfast gatherings<br />
_____<strong>In</strong>terfaith Service<br />
_____Plenary #2- Dr. Nancy Ramsay<br />
_____Discussion Groups<br />
_____ACPE <strong>Annual</strong> Member/Business Meeting Luncheon<br />
_____Workshop Selection – Please select your THREE choices, in order of preference, indicating 1 st , 2 nd , or 3 rd . Space is limited but we will do our best to accommodate your 1 st choice.<br />
___F1. Teach Research in CPE Residency Programs<br />
___F5. From Personal Growth to Social & Political Advocacy – CPE in Two Urban Settings<br />
___F2. Creating Healing Environments – Remembrance of One’s<br />
___F6. Self-Supervision of Work with Students<br />
Past, Embracing the Present and Proclaiming One’s Future<br />
___F7. Purpose, Practice & Proclamation for Pastoral Caregivers of the Beloved <strong>Community</strong> in the<br />
___F3. Self-Assessed Spiritual Skill Changes Reported by CPE Residents<br />
Post Racial Era<br />
and <strong>In</strong>terns<br />
___F8. Our Children, Our Hope, Our Future: Roles of a Pediatric Chaplain<br />
___F4. Healing Social and <strong>Community</strong> Violence<br />
_____Network Meetings – Please indicate which Network Session you will be attending. Select only one.<br />
___Racial Ethnic Multicultural (REM) <strong>Annual</strong> Business Meeting<br />
___Buddhist ___<strong>In</strong>ternational ___Research<br />
___Clinical Members ___Jewish Supervisors ___Retired Supervisors<br />
___Congregational/<strong>Community</strong>-based CPE ___Peace (PCNSR) ___VA Chaplains<br />
___Gay/Lesbian/Bisexual/Transgender ___Supervisory Education ___Red Cross SAIRS (includes excursion see brochure for details)<br />
_____Friday Night’s 25 th Birthday Party & Celebration<br />
Saturday, February 11 th<br />
_____Plenary #3-Special <strong>In</strong>vited Guest from the US Surgeons’ General Office<br />
_____Memorial Service/Closing Ceremony<br />
_____Retirement Celebration for Bishop Teresa Snorton, ACPE’s Past Executive Director<br />
Part A. Total INCLUSIVE REGISTRATION FEES Due to ACPE/REM $____________<br />
Page 2 of 4
Part A: One-Day <strong>Registration</strong> Options<br />
The included events are listed under each ONE DAY REGISTRATION option, a ticket will be required for entry to some of these events.<br />
It is important that you indicate below which of these events that you WILL / WILL NOT attend.<br />
There are additional events and guest tickets available for participation on the last page of this registration document.<br />
One Day <strong>Registration</strong> – Wednesday, February 8 th<br />
ACPE Supervisors, Assoc. Supervisors, Candidates, Clinical Members, and Other Pastoral Care Professionals $75.00 _____<br />
CPE and Seminary Students; Retired Supervisors, Retired Members, Spouses / Significant Others $ 40.00 _____<br />
____ACPE’s Presidential Dinner in community with REM’s 25 th Anniversary<br />
One Day <strong>Registration</strong> - Thursday, February 9 th<br />
ACPE Supervisors, Assoc. Supervisors, Candidates, Clinical Members, and Other Pastoral Care Professionals $140.00 _____<br />
CPE and Seminary Students; Retired Supervisors, Retired Members, Spouses / Significant Others $ 80.00 _____<br />
_____<strong>In</strong>terfaith Service<br />
_____Plenary #1 Dr. Emmanuel Lartey<br />
_____Discussion Group<br />
_____Workshop Selection - Please select your THREE choices, in order of preference, indicating 1 st , 2 nd , or 3 rd . Space is limited but we will do our best to accommodate your 1 st choice.<br />
___T1. Teach Research in CPE Residency Programs<br />
___T5. Coming Out ~ Coming <strong>In</strong>: Pastoral Care with Sexual Minorities<br />
___T2. Use of Self in CPE Supervision<br />
___T6. Supervising Wounded Healers: Through Trauma Psychology & Culturally Sensitive Care<br />
___T3. SILENT CRY: <strong>In</strong> Search of Harmony on Gold Mountain ___T7. Pastoral Care to Spiritual Care: Embracing Our Future<br />
– The Yin-Yang Way of Pastoral Care ___T8. A Black Woman’s Journey of <strong>In</strong>terdependence: How African Spirituality and Womanist<br />
___T4. Embracing the Present: Mindfulness Meditation as Self-Care<br />
Theology Have Impacted My <strong>In</strong>tercultural Pastoral Care<br />
for Pastoral Care Givers<br />
___T9. Navigating the Certification Process<br />
_____ACPE Regional Meetings<br />
___Northeast Region: Maine, Massachusetts, New Hampshire, Rhode Island, Vermont ___North Central Region: Illinois (Northern), Iowa, Michigan (Upper Penninsula) Minnesota, North Dakota, South Dakota, Wisconsin<br />
___Eastern Region: Connecticut, Delaware, New Jersey, New York, Pennsylvania ___South Central Region: Colorado, Illinois (South), Kansas, Missouri, Nebraska, Wyoming<br />
___Mid-Atlantic Region: District of Columbia, Maryland, No. Carolina, Virginia, W. Virginia ___Southwest Region: Arkansas, Louisiana, New Mexico, Oklahoma, Texas<br />
___Southeast Region: Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee ___Pacific Region: Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington<br />
___East Central Region: <strong>In</strong>diana, Kentucky, Michigan (except Upper Peninsula), Ohio, Pennsylvania (Western)<br />
_____REM <strong>In</strong>vitational 25 th Anniversary Celebration at Howard University (transportation is included, pre-registration is required)<br />
One Day <strong>Registration</strong> - Friday, February 10 th<br />
ACPE Supervisors, Assoc. Supervisors, Candidates, Clinical Members, and Other Pastoral Care Professionals $140.00 _____<br />
CPE and Seminary Students; Retired Supervisors, Retired Members, Spouses / Significant Others $ 80.00 _____<br />
_____Denomination / Faith Group Breakfasts – Please indicate which breakfast you will be attending. Spouses are welcome at this event, please indicate the number attending.<br />
While most of these breakfasts are sponsored by the respective faith tradition, some may require an additional fee.<br />
___Alliance of Baptist ___ Lutheran ___ Seventh-Day Adventist<br />
___American Baptist ___ Pentecostal/Charismatic/Assemblies of God ___ Southern Baptist<br />
___Baptist General Convention of Texas ___ Presbyterian-USA ___ United Church of Christ<br />
___Cooperative Baptist Fellowship ___ Reformed Church in America/Christian Reform ___ United Methodist<br />
___ Roman Catholic<br />
See ADDITIONAL TICKETS and EVENTS (page 4) to register for the Christian Church (Disciples of Christ), Episcopal, or Unitarian Universalists breakfast gatherings<br />
_____<strong>In</strong>terfaith Service<br />
_____Plenary #2- Dr. Nancy Ramsay<br />
_____Discussion Groups<br />
_____ACPE <strong>Annual</strong> Member/Business Meeting Luncheon<br />
_____Workshop Selection – Please select your THREE choices, in order of preference, indicating 1 st , 2 nd , or 3 rd . Space is limited but we will do our best to accommodate your 1 st choice.<br />
___F1. Teach Research in CPE Residency Programs<br />
___F5. From Personal Growth to Social & Political Advocacy – CPE in Two Urban Settings<br />
___F2. Creating Healing Environments – Remembrance of One’s<br />
___F6. Self-Supervision of Work with Students<br />
Past, Embracing the Present and Proclaiming One’s Future<br />
___F7. Purpose, Practice & Proclamation for Pastoral Caregivers of the Beloved <strong>Community</strong> in the<br />
___F3. Self-Assessed Spiritual Skill Changes Reported by CPE Residents<br />
Post Racial Era<br />
and <strong>In</strong>terns<br />
___F8. Our Children, Our Hope, Our Future: Roles of a Pediatric Chaplain<br />
___F4. Healing Social and <strong>Community</strong> Violence<br />
_____Network Meetings – Please indicate which Network Session you will be attending. Select only one.<br />
___Racial Ethnic Multicultural (REM) <strong>Annual</strong> Business Meeting<br />
___Buddhist ___<strong>In</strong>ternational ___Research<br />
___Clinical Members ___Jewish Supervisors ___Retired Supervisors<br />
___Congregational/<strong>Community</strong>-based CPE ___Peace (PCNSR) ___VA Chaplains<br />
___Gay/Lesbian/Bisexual/Transgender ___Supervisory Education ___Red Cross SAIRS (includes excursion see brochure for details)<br />
_____Friday Night’s 25 th Birthday Party & Celebration<br />
One Day <strong>Registration</strong> - Saturday, February 11 th<br />
ACPE Supervisors, Assoc. Supervisors, Candidates, Clinical Members, and Other Pastoral Care Professionals $100.00 _____<br />
CPE and Seminary Students; Retired Supervisors, Retired Members, Spouses / Significant Others $ 60.00 _____<br />
_____Plenary #3-Special <strong>In</strong>vited Guest from the US Surgeons’ General Office<br />
_____Memorial Service/Closing Ceremony<br />
_____Retirement Celebration for Bishop Teresa Snorton, ACPE’s Past Executive Director<br />
Part A. Total ONE‐DAY REGISTRATION FEES Due to ACPE/REM $____________<br />
Page 3 of 4
Part B: Additional Tickets and Events<br />
Designated Meetings/Gathering for Stated Groups Only:<br />
VA Military Chaplains’ Meeting, Wednesday, February 8 th , 4pm I am a VA Military Chaplain, and will attend. _____<br />
ACPE Past Presidents’ Breakfast, Saturday, February 11 th , 7am I am an ACPE Past President, and will attend. _____<br />
Seminary Advisory Councils’ Breakfast, Saturday, February 11 th , 7am I am a Seminary Advisory Rep, and will attend. _____<br />
Religious Endorsing Representatives Breakfast, Saturday, February 11 th , 7am I am a Religious Endorsing Rep, and will attend. _____<br />
Clinical Members’ Advisory Council Breakfast, Saturday, February 11 th , 7am I am on the Clinical Members’ Advisory Council, and will attend. _____<br />
Red Cross Training, Tuesday, February 7 th AND Wednesday, February 8 th<br />
See Brochure for Full Descriptions and Qualifications N/C _____<br />
ACPE’s Academy for Continuing Education, Wednesday, February 8 th<br />
9am Management 103: The Best Laid Plans – The Process of Why, What, & How in Strategic Planning $100.00 _____<br />
9am Leadership Forum 130: Seminaries & ACPE Partners in Education: The Past, Present & the Future<br />
(required at no charge for ACPE’s 2012 National Leadership) $50.00 _____<br />
12pm BOXED LUNCH $28.00 _____<br />
1pm Management 203: Managing Others Starts with You $100.00 _____<br />
1pm Leadership Forum 131/Teaching and Supervisory Arts 120: Discerning Strong Applicants for CPE Supervisory Education<br />
(required at no charge for ACPE’s 2012 National Leadership) $50.00 _____<br />
1pm Academy Workshop: A Curiosity for Life Coaching $38.00 _____<br />
Faith Group Breakfasts, Friday, February 10 th<br />
Guest Name(s)_________________________________________________________<br />
7am Christian Church (Disciples of Christ) $28.00 X_____ $_____<br />
7am Episcopal Faith Group Breakfast $28.00 X_____ $_____<br />
7am Unitarian Universalist Faith Group Breakfast $28.00 X_____ $_____<br />
FCPE’s <strong>Annual</strong> Donor Recognition Celebration, Friday, February 10 th<br />
Guest Name(s)_________________________________________________________<br />
6pm By making a donation of $100 or more, you are cordially invited to attend this Recognition Celebration. $100.00 or more X_____ $_____<br />
Ticket proceeds will be forwarded to the Foundation on your behalf.<br />
per person donation<br />
Consult your tax professional for reporting this donation.<br />
Guest Tickets (purchase required for non-registered participants)<br />
Guest Name(s)_________________________________________________________<br />
6pm, Wednesday, February 8th - Presidential Dinner $75.00 X_____ $_____<br />
7pm, Thursday, February 9 th – Howard University $20.00 X_____ $_____<br />
11:30am, Friday, February 10 th – ACPE’s <strong>Annual</strong> Member Meeting $40.00 X_____ $_____<br />
9pm, Friday Night’s Birthday Party and Entertainment $30.00 X_____ $_____<br />
Part B. Total Ticket Fees Due to ACPE/REM $____________<br />
Part C: Late <strong>Registration</strong> Fees<br />
Early Bird <strong>Registration</strong> Ends December 16 th<br />
All <strong>Registration</strong>s (<strong>In</strong>clusive and One Day) received after December 16th<br />
will be required to pay this additional fee!<br />
ACPE Supervisors, Assoc. Supervisors, Candidates, Clinical Members, and Other Pastoral Care Professionals $100.00 _____<br />
CPE and Seminary Students; Retired Supervisors, Retired Members, Spouses / Significant Others $50.00 _____<br />
Part C. Total LATE REGISTRATION Fees Due to ACPE/REM $____________<br />
Page 4 of 4
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