1 Start 2 Complete Welcome to the PHW Collaborative Pledge Form! We are so glad you are taking the first steps to partnering with us. Please read all instructions and requirements before proceeding to the form. What is The Collaborative Pledge? The purpose of the Collaborative Pledge is to ensure that your faith community and PHW are on the same page about being committed to health as a faith issue. We also use the information you provide us in the pledge to get to know what your health priorities are, and to be better equipped to walk alongside your faith community in your journey to health and wholeness. PLEASE NOTE: This Collaborative Pledge form is NOT a grant application. If you are eligible to apply for a grant, we will include an application link in your Collaborative Pledge acceptance email. Information on our current grant offerings can be found at healthandwholeness.org/mini-grants. Tips for filling out the Collaborative Pledge: Consider the Collaborative Pledge as your opportunity to introduce yourself to us. We want to know what's most important to your faith community with respect to our FOCUS AREAS. PHW currently has seven focus areas: We want to know where your health ministry plans to focus its energy in one or more of these focus areas. WE DO NOT EXPECT YOU TO BE ACTIVELY PURSUING WORK IN EVERY FOCUS AREA. Don't feel like you have to impress us by doing something in every area. We are only interested in knowing what's important to you. Please note: You must complete this form in one sitting. You cannot save your work and come back. We recommend typing your answers in a separate document before you begin filling out the form in case the form does not successfully submit for any reason. If you have any questions, don't hesitate to contact phwinfo@ncchurches.org. Now that we've got all that out of the way, let's get started! Collaborative Pledge Agreement By submitting this application you are agreeing to the PHW requirements of: Maintaining tobacco free buildings on worship grounds Serving healthy food and drink options at congregational activities, events, and meetings Asking Faith Leader to complete the Clergy Commitment (this should be done prior to completing the Collaborative Pledge form) Sharing the message of health as a faith issue Integrating at least one church-based activity based on one of the seven focus areas of the PHW program: tobacco/nicotine education, healthy eating, increased physical activity, mental health advocacy and education, overdose/substance use, HIV, or healthy aging. Additionally, by submitting this application, I certify that I and my faith community adhere to the following requirements: The organization is a worshiping faith community that meets regularly at a physical location in North Carolina. The Health Lead (person completing this form) is either an active member of the congregation or on staff at the time of submission. Agreement to the PHW requirements * I agree Contact Information Congregation Contact Information Name of Faith Community * Street Address (The address where your faith community meets for worship.) * City * Postal Code * Country * United States State/Province * District/County * Mailing Address (Please provide address, city, state, and zip code. If mailing and street address are the same, type 'same.' * PHW Health Lead's Contact Information Name Prefix - None -Ald.Asm.Assembly MemberAssemblymanAssemblywomanBishopBorough PresidentBrBrotherCapt.CoachCommissionerComptrollerCongressmanCongresswomanCouncil MemberCouncilmanCouncilwomanDeaconDeanDet.Dr.FatherFr.Gov.GovernorHon.ImamLt. GovernorMayorMinisterMonsignorMr.Mr. & Mrs.Mr. & Ms.Mrs.Mrs. & Mr.Ms.Ms. & Mr.Msgr.PastorPresidentProf.ProfessorRabbiRep.RepresentativeRev.Rev. CanonRev. DeaconRev. Dr.ReverendSen.SenatorSgtSisterSr.Sra.The HonorableThe VenerableDr. and Mr.Dr. and Ms.ElderMr. and Mrs.Mr. and Ms.Ms. and Mr.Rev Dr.The Rev.The Rev. & Mr.The Rev. DeaconThe Rev. Dr.The ReverendThe Right. Rev.The Rt. Rev.Drs.Dr. and Mrs.Dr. & Rev.The Rev. and MsMissThe Rev. CanonMajorRev. Msgr.CanonRev.Rev.The Rev. Fr.The Rev. & Mrs.Bishop EmeritusPastorsRectorThe Rev. ElderThe Very Rev.ApostleProphetApostle Dr.Reverend Dr.RevsMinister Dr.ProphetessCo-PastorOverseerChaplainPastor, Rev.Dr. Rev.EldressPastor Dr.AbbotBishop Dr. First Name * Last Name * Name Suffix - None -AIACPACRNPCSWDDSDPADPMDSWEsq.IIIIIIVJDJr.LFDLMSWLPCM.D.M.Div.MHSMPAMSWOFMOPPEPh.DRNRSMS.J.Sr.VVIVIIDVMPA,MPHRN, BSN, M.DivMSMA, RHRN MPHRN,PNRN, BSN Phone Number * Email * Faith Leader's Title and Contact Information Name Prefix - None -Ald.Asm.Assembly MemberAssemblymanAssemblywomanBishopBorough PresidentBrBrotherCapt.CoachCommissionerComptrollerCongressmanCongresswomanCouncil MemberCouncilmanCouncilwomanDeaconDeanDet.Dr.FatherFr.Gov.GovernorHon.ImamLt. GovernorMayorMinisterMonsignorMr.Mr. & Mrs.Mr. & Ms.Mrs.Mrs. & Mr.Ms.Ms. & Mr.Msgr.PastorPresidentProf.ProfessorRabbiRep.RepresentativeRev.Rev. CanonRev. DeaconRev. Dr.ReverendSen.SenatorSgtSisterSr.Sra.The HonorableThe VenerableDr. and Mr.Dr. and Ms.ElderMr. and Mrs.Mr. and Ms.Ms. and Mr.Rev Dr.The Rev.The Rev. & Mr.The Rev. DeaconThe Rev. Dr.The ReverendThe Right. Rev.The Rt. Rev.Drs.Dr. and Mrs.Dr. & Rev.The Rev. and MsMissThe Rev. CanonMajorRev. Msgr.CanonRev.Rev.The Rev. Fr.The Rev. & Mrs.Bishop EmeritusPastorsRectorThe Rev. ElderThe Very Rev.ApostleProphetApostle Dr.Reverend Dr.RevsMinister Dr.ProphetessCo-PastorOverseerChaplainPastor, Rev.Dr. Rev.EldressPastor Dr.AbbotBishop Dr. First Name * Last Name * Name Suffix - None -AIACPACRNPCSWDDSDPADPMDSWEsq.IIIIIIVJDJr.LFDLMSWLPCM.D.M.Div.MHSMPAMSWOFMOPPEPh.DRNRSMS.J.Sr.VVIVIIDVMPA,MPHRN, BSN, M.DivMSMA, RHRN MPHRN,PNRN, BSN Phone Number * Email * Has your faith leader completed the Clergy Commitment? * Yes No (This will delay your Collaborative Pledge acceptance.) Congregation Specifics Denomination * - Select -Alliance BaptistAfrican Methodist EpiscopalAMEZApostolicBahaiBaptistChristian Methodist EpiscopalCooperative Baptist FellowshipDisciples of ChristEpiscopalEvangelical LutheranFree Will BaptistGeneral BaptistIslamicJewishLutheran - Missouri SynodMennoniteMetropolitan Community ChurchMissionary BaptistMoravianNon-DenominationalOtherPentecostal Holiness ChurchPresbyterianReformed ChurchReigious Society of FriendsRoman CatholicSeventh Day AdventistSouthern BaptistUMCUnited Church of ChristUnity Fellowship Church MovementNot affiliated with a denominationUnitarian UniversalistChurch of the Nazarene Racial and Ethnic Make-Up * - Select -Predominantly Bi/MultiracialPredominantly Black/African American/African DiasporaPredominantly International (not born in USA)Predominantly Latino/HispanicPredominantly White/Caucasian/European DescentOther - MixedPrefer not to disclosePredominantly Middle Eastern Size of Congregation * 1-50 51-99 100-199 200-300 300+ Being Healthy, Being Faithful-Tell us about your Health Ministry How does your health team or worship leader share health as a faith issue? Please check all that apply. * During worship services Bible Study In worship literature Small group study Other Please share additional details about how your congregation integrates health as a faith issue either from the areas above or in other unique ways. * Year Health Ministry Started * Joys and Challenges of the Past 12 Months In this section, we hope to get a better idea of what your health ministry has been up to in the 12 months prior to you filling out this application. In each of our focus areas, please tell us if your health ministry's efforts are BEGINNING, SUSTAINING, EXPANDING, or NOT A FOCUS. Remember, we do NOT expect you to have been active in every focus area. We want to know what is important to you. Mental Health - PAST * - Select -BeginningSustainingExpandingNot a focus at this time Healthy Eating - PAST * - Select -BeginningSustainingExpandingNot a focus at this time Increasing Physical Activity - PAST * - Select -BeginningSustainingExpandingNot a focus at this time Tobacco/Nicotine Education - PAST * - Select -BeginningSustainingExpandingNot a focus at this time Overdose Crisis - PAST * - Select -BeginningSustainingExpandingNot a focus at this time Healthy Aging - PAST * - Select -BeginningSustainingExpandingNot a Focus at this time HIV - PAST * - Select -BeginningSustainingExpandingNot a focus at this time Using as much detail as possible, please describe the scope of your health ministry's work over the past twelve months. Please share with us any joys or challenges you experienced as you went about this work. * Goals and Plans for the Next 12 Months Use this section to tell us where your health ministry is headed in the next 12 months. In each of our focus areas, please tell us if your health ministry's efforts are BEGINNING, SUSTAINING, EXPANDING, or NOT A FOCUS. Remember, we do NOT expect you to be actively pursuing every focus area. We want to know what is important to you. For each applicable focus area, please provide a detailed paragraph of what you hope to accomplish in the coming year. If you do not have plans to work in a particular focus area, simply type N/A. Mental Health - FUTURE * - Select -BeginningSustainingExpandingNot a focus at this time In one paragraph, please carefully describe your health ministry's plans regarding mental health in the NEXT 12 months. If this does not apply to you simply type n/a. * Healthy Eating - FUTURE * - Select -BeginningSustainingExpandingNot a focus at this time In one paragraph, please carefully describe your health ministry's plans regarding healthy eating in the NEXT 12 months. If this does not apply to you simply type n/a. * Increasing Physical Activity - FUTURE * - Select -BeginningSustainingExpandingNot a focus at this time In one paragraph, please carefully describe your health ministry's plans regarding increasing physical activity in the NEXT 12 months. If this does not apply to you simply type n/a. * Tobacco/Nicotine Education- FUTURE * - Select -BeginningSustainingExpandingNot a focus at this time In one paragraph, please carefully describe your health ministry's plans regarding tobacco/nicotine education in the NEXT 12 months. If this does not apply to you simply type n/a. * Overdose Crisis/Substance Use - FUTURE * - Select -BeginningSustainingExpandingNot a focus at this time In one paragraph, please carefully describe your health ministry's plans regarding the overdose crisis/substance use in the NEXT 12 months. If this does not apply to you simply type n/a. * Healthy Aging - Future * - Select -BeginningSunstainingExpandingNot a focus at this time In one paragraph, please carefully describe your health ministry's plans regarding the healthy aging in the NEXT 12 months. If this does not apply to you simply type n/a. * HIV - FUTURE * - Select -BeginningSustainingExpandingNot a focus at this time In one paragraph, please carefully describe your health ministry's plans regarding the HIV in the NEXT 12 months. If this does not apply to you simply type n/a. * Partners in Health and Wholeness History How did you hear about PHW? * Choosing from the statements below, please tell us how we can continue to support you and your faith community in your journey to health and wholeness. * - Select -I would like more support from my regional coordinatorI would like the same amount of support from my regional coordinatorI would like less support from my regional coordinatorI do not know who my regional coordinator isOther If you are requesting more support, please tell us specifically what type of support would be most benefical in the next 12 months. Wrap Up Thank you for joining us as a Partner in Health and Wholeness. Is there anything you would like to add that would help us better support your efforts or that you would like us to know? What's Next? You will receive an automated confirmation email when this form is successfully submitted. A copy of your responses will be sent to you and your faith leader. This confirmation email does not indicate formal acceptance into The PHW Collaborative, simply that your application has been received. You will receive a formal acceptance from our office within three weeks. If we are offering grants that you are eligible for and we are in an open cycle, you will receive instructions on how to apply. Please direct any questions to phwinfo@ncchurches.org. We will be glad to assist you! Submit
