Event Registration Survey

UCC Disaster Ministries presents:
A Disaster Trauma Retreat for Clergy - "Come Away...Rest Awhile" John 6:31

UCC Disaster Ministries will be hosting four clergy retreats throughout areas impacted by Hurricane Florence, 2018. Rev. Dr. Martha R. Jacobs, Coordinator for UCC Disaster Ministries Chaplains, Senior Minister - First Congregational Church in Chappaqua NY, Leadership Team for American Red Cross, Former Chair of the National VOAD Spiritual and Emotional Care Committee, and Professional Chaplain for 25 years will facilitate.

There is no registration fee. Lodging and meals are included. Each retreat location will be limited to 20 participants. You do not need to attend the retreat closest to you. Please chose from one location (Raleigh, New Bern, Elizabeth City, Wilmington). Each event will begin at 4 p.m. on first day and conclude at 4 p.m. the second day. Meals are included. Spouses and significant others are invited but will be charged for meals.

Please fill out this survey to get registered.

Question Title

* 1. Will you be attending Disaster Trauma Retreat?

Yes

Not this time but keep me in for future events

Question Title

* 2. Your contact info:

First Name

Last Name

Address

Organization

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Do you have any dietary restrictions? (Select all that apply.)

I do not have any dietary restrictions.

Vegetarian

Vegan

Lactose Intolerant

Gluten Free

No Shellfish

Other (please specify)

Question Title

* 4. Which event will you attend?

New Bern, July 15 - 16, 2019

Elizabeth City, July 17 - 18, 2019

Raleigh, July 22 - 23, 2019

Wilmington, July 24 - 25, 2019

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* 5. How would you like to receive additional information about Disaster Trauma Retreat?

Text

Both