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    2015 PSM Regional Gathering Registration Form - Charlottesville, VA

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    Catholic Charities USA
    This document is a registration form for the Parish Social Ministry Regional Gathering being held in Charlottesville, Virginia from April 17-18, 2015. It collects contact information for two attendees, including their organization and job title. It also collects payment information and asks attendees to select preference for language, event tracks, and dietary requirements.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd

    2015 PSM Regional Gathering Registration Form - Charlottesville, VA

    Uploaded by

    Catholic Charities USA
    124 views7 pages
    This document is a registration form for the Parish Social Ministry Regional Gathering being held in Charlottesville, Virginia from April 17-18, 2015. It collects contact information for two attendees, including their organization and job title. It also collects payment information and asks attendees to select preference for language, event tracks, and dietary requirements.

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    2015 PSM Regional Gathering Registration Form - Charlottesville, VA

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    This document is a registration form for the Parish Social Ministry Regional Gathering being held in Charlottesville, Virginia from April 17-18, 2015. It collects contact information for two attendees, including their organization and job title. It also collects payment information and asks attendees to select preference for language, event tracks, and dietary requirements.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    124 views7 pages

    2015 PSM Regional Gathering Registration Form - Charlottesville, VA

    Uploaded by

    Catholic Charities USA
    This document is a registration form for the Parish Social Ministry Regional Gathering being held in Charlottesville, Virginia from April 17-18, 2015. It collects contact information for two attendees, including their organization and job title. It also collects payment information and asks attendees to select preference for language, event tracks, and dietary requirements.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    of 7

    Catholic Charities USA

    Individual Registration Form


    PARISH SOCIAL MINISTRY REGIONAL GATHERING CHARLOTTESVILLE | APR 17-18, 2015| CHARLOTTESVILL

    Attendee 1
    Attendee
    Organization:
    Job Title:
    Address:
    City/State/Zip:

    Phone:

    Email:

    Fax:

    Parish:
    Emergency
    Contact
    Use the (name/phone)
    dropdown to find your main Diocesan agency (state, city).
    If you are not affiliated with a Catholic Charities agency,
    select Not Applicable.
    Use the dropdown to find your Affiliate Member organization.
    If you are not affiliated with an Affiliate Member, select Not
    Applicable.

    Twitter

    How are you related to the Agency?


    Check this box if you DO NOT want to be included in our Attendee Lists.
    Language preference for this event
    Special Needs/Dietary Requirements?

    Attendee 2
    Attendee
    Organization:
    Job Title:
    Address:
    City/State/Zip:

    Phone:

    Email:

    Fax:

    Parish:
    Emergency
    Contact
    Use the (name/phone)
    dropdown to find your main Diocesan agency (state, city).
    If you are not affiliated with a Catholic Charities agency,
    select Not Applicable.
    Use the dropdown to find your Affiliate Member organization.
    If you are not affiliated with an Affiliate Member, select Not
    Applicable.

    Twitter

    How are you related to the Agency/Organization?


    Check this box if you DO NOT want to be included in our Attendee Lists.
    Language preference for this event
    Special Needs/Dietary Requirements?

    If there are more than 2 attendees with one payment method, please attach additional forms.
    In the quantity field below, enter the total number of registrations. The form will calculate the total.

    Quantity

    Registration Type

    Unit Price

    Individual (early bird) Before October 31, 2014

    $15.00

    Individual (full) After October 31, 2014

    $25.00

    Total:

    Total

    Payment Method
    My check is enclosed

    VISA

    Mastercard

    American Express Discover

    Name on Card:

    Exp. Date:

    Card Number:

    Security:

    Signature:
    Send completed forms to:
    Catholic Charities USA
    2050 Ballenger Avenue, Suite 400 | Alexandria, VA 22314
    Phone: (703) 549-1656 | Secure Fax: (703) 549-1728

    Not Applicable
    10163582 - AK - Anchorage
    10163583 - AK - Juneau
    10163584 - AL - Birmingham
    00038390 - AL - Mobile
    10163585 - AR - Little Rock
    10163586 - AS - Pago Pago
    00005299 - AZ - Phoenix (Catholic Charities)
    10133020 - AZ - Phoenix (Found. for Sr. Living)
    00059166 - AZ - Tucson (Southern AZ)
    00040646 - CA - Fresno
    00065313 - CA - Los Angeles
    00034227 - CA - Oakland (East Bay)
    00023508 - CA - Sacramento
    00065203 - CA - San Bernadino
    00005389 - CA - San Diego
    00043127 - CA - San Francisco
    00005627 - CA - San Jose (Santa Clara)
    00038391 - CA - Santa Ana (Orange County)
    00034066 - CA - Santa Rosa
    10369477 - CA - Seaside (Monterey)
    10150241 - CA - Stockton
    10163594 - CO - Colorado Springs
    10139899 - CO - Denver
    10161787 - CO - Pueblo
    00022379 - CT - Bridgeport (Fairfield)
    00085445 - CT - Hartford
    10163595 - CT - Norwich
    00005418 - DC - Washington
    10148272 - DE - Wilmington
    00075253 - FL - Jacksonville (St. Augustine)
    00005427 - FL - Miami
    10162845 - FL - Orlando (Central FL)
    10093927 - FL - Palm Beach
    00038395 - FL - Pensacola (NW Florida)
    00038394 - FL - St. Petersburg
    00074495 - FL - Venice
    00038421 - GA - Atlanta
    10163968 - GA - Savannah
    10144625 - GU - Barrigada (Hagatna)
    00038396 - HI - Honolulu
    10369904 - IA - Davenport (Social Action)
    00034765 - IA - Des Moines
    00075264 - IA - Dubuque
    00035410 - IA - Sioux City
    10163969 - ID - Boise
    10377047 - IL (Belleville) (Catholic Charities of So. IL)
    00005286 - IL - Chicago
    10092399 - IL - Joliet
    10163970 - IL - Peoria
    00020888 - IL - Springfield
    00005269 - IN - Evansville
    00005429 - IN - Ft Wayne
    00038397 - IN - Gary

    10372188 - IN - Indianapolis
    00036755 - KS - Dodge City
    00036893 - KS - Kansas City (NE Kansas)
    00065188 - KS - Salina
    00005360 - KS - Wichita
    00038399 - KY - Covington
    00005425 - KY - Lexington
    00036857 - KY - Louisville
    10163990 - KY - Owensboro
    10163991 - LA - Alexandria
    00005423 - LA - Baton Rouge
    00058662 - LA - Houma
    10370498 - LA - Lafayette
    10163993 - LA - Lake Charles
    00058220 - LA - New Orleans
    10431202 - LA - Shreveport
    00035408 - MA - Boston
    00074964 - MA - Fall River
    10165052 - MA - Springfield
    00072210 - MA - Worcester
    00005629 - MD - Baltimore
    10092778 - ME - Portland
    10370483 - MI - Detroit
    00036870 - MI - Grand Rapids (West MI)
    00005288 - MI - Kalamazoo
    00065076 - MI - Marquette (Upper Peninsula)
    00038401 - MN - Minneapolis (St. Paul)
    10391345 - MN - New Ulm
    00012131 - MN - Saint Cloud
    00075266 - MN - Winona
    10165271 - MO - Jefferson City (Central & Northern MOi)
    00038402 - MO - Kansas City
    00023372 - MO - Saint Louis
    10412461 - MO - Springfield (Southern MO)
    10478696 - MP - Karidat Social Services
    00036895 - MS - Biloxi
    10093276 - MS - Jackson
    10165272 - MT - Helena
    10142121 - NC - Charlotte
    10092401 - NC - Raleigh
    00065075 - ND - Fargo
    00036979 - NE - Omaha
    10165274 - NJ - Camden
    00005334 - NJ - Newark
    00084093 - NJ - Paterson
    00005604 - NJ - Perth Amboy (Metuchen)
    10149610 - NJ - Trenton
    10145767 - NM - Albuquerque (Santa Fe)
    10129581 - NM - Gallup
    10370188 - NM - Las Cruces
    00005535 - NV - Las Vegas (Southern NV)
    10165273 - NV - Reno (Northern NV)
    00038403 - NY - Albany
    00034792 - NY - Brooklyn

    00005008 - NY - Buffalo
    00036869 - NY - Hicksville
    10093926 - NY - New York
    00035407 - NY - Ogdensburg
    00036858 - NY - Rochester
    10153832 - NY - Syracuse
    00064801 - OH - Cincinnati (Southern OH)
    00038407 - OH - Cleveland
    10162846 - OH - Columbus
    00005410 - OH - Dayton (Miami Valley)
    10165294 - OH - Steubenville
    00034764 - OH - Toledo
    00034259 - OH - Youngstown
    00033934 - OK - Oklahoma City
    00065229 - OR - Portland
    00005290 - PA - Allentown
    10165296 - PA - Altoona
    00065465 - PA - Greensburg
    00043538 - PA - Harrisburg
    00005301 - PA - Philadelphia
    00034228 - PA - Pittsburgh
    00038410 - PA - Wilkes Barre (Scranton)
    10165327 - PR - San Juan
    10165297 - RI - Providence
    00035404 - SC - Charleston
    00065220 - SD - Rapid City
    10136687 - TN - Knoxville (East TN)
    00007600 - TN - Memphis
    00026447 - TN - Nashville
    00005333 - TX - Amarillo
    10146072 - TX - Austin (Central TX)
    10165318 - TX - Beaumont (Southern TX)
    10165320 - TX - Corpus Christi
    00005303 - TX - Dallas
    00015248 - TX - Fort Worth
    00023371 - TX - Houston (Galveston)
    10369905 - TX - Laredo
    00038411 - TX - Lubbock
    10165321 - TX - Odessa (San Angelo)
    00005851 - TX - San Antonio
    10165319 - TX - San Juan (Brownville)
    10369484 - TX - Tyler
    00072500 - UT - Salt Lake City
    10153534 - VA - Arlington
    00005294 - VA - Richmond
    00005296 - VA - Virginia Beach
    10165328 - VI - St. Thomas
    00035023 - VT - Burlington
    10092405 - WA - Seattle (Western WA)
    00058515 - WA - Spokane
    00005417 - WA - Yakima
    10165323 - WI - Green Bay
    00072637 - WI - La Crosse
    10092783 - WI - Madison

    10142123 - WI - Milwaukee
    00075145 - WI - Superior
    00036902 - WV - Wheeling
    00005302 - WY - Cheyenne
    10478696 - MP - Karidat Social Services
    Not Applicable
    Board Member
    Employee (branch office)
    Employee (main agency)
    Volunteer
    Select one (optional)
    1 Financial Stability
    2 Business Venture Services
    3 Children's Assessment Center
    4 HOMES Housing Opportunity Model
    5 Casa Housing Property
    6 Development Office
    AG Tracks Available
    Track 1 - Advocacy
    Track 2 - Direct Service
    Track 3 - Immigration
    Track 4 - Parish Leadership Development
    Options (language)
    English
    Spanish
    French
    Options (PSM-RG -event Track)
    Track 1 - Moving from Multitude to Community
    Track 2 - The Holy Spirit Speaking to Us Today
    Track 3 - Why Fair Trade?
    Track 4 - Poverty & Economic Inequality
    Options (PSM-RG -event Track) 2nd half
    Track 5 - Models of Collaboration
    Track 6 - The Holy Spirit Speaking to Us Today: Gifts of Diversity and Unity
    Track 7 - Pope Francis, Young Adults & the Social Mission of the Church
    Track 8 - Poverty & Economic Inequality
    Not Applicable
    10442768 - Catholic Charities of Missouri, LLC
    10478366 - Catholic Legal Services Archdiocese of Miami, Inc.
    10408108 - Center of Concern
    10471047 - Cross Catholic Outreach
    10429299 - Dominican Sisters - Grand Rapids
    10416491 - Prefecture Apostolic of the Mashall Islands
    10143371 - Society of the Divine Savior
    (Select One)
    Yes - I will remain for the meal

    No - I will NOT remain for the meal


    (Select One)
    Yes - I will attend the Site Tout to Lanakila Multi-Purpose Senior Center
    No - I will NOT attend Site Tour to Lanakila Multi-Purpose Senior Center

    10/28/2013

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