National Black Woman Heal Day Registration Form
Lilada's Livingroom is excited to have you join our efforts on National Black Woman Heal Day! on April 1st, 2015. We want you to use the depth of your creativity to create an event that will be an exciting, empowering, equipping and educating event for Black women and girls in your community. Please use this form to let us know the wonderful event that you will be hosting on April 1st, 2015 to honor Lilada's Livingroom's National Black Woman Heal Day!

The Goals of National Black Woman Heal! Day are to:
-To inspire Black survivors across the nation to embark upon a healing journey
-To educate Black communities about child sexual abuse and its impact
-To equip local communities to implement Afro-centric healing and prevention responses to sexual abuse in their  communities

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Hostess Name *
Email Address *
Phone Number *
Event City and State *
Type of Gathering *
Please check the type of event will you be hosting on April 1st.
Event Details
Please describe the details of the event will you be hosting on April 1st. You may provide this information at a later date if you are still formulating your ideas. If you are blogging or making a media mention, please briefly detail the topic of your blog and/or discussion below.
Target Population
Who is your event designed to reach out to?
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Name of Location of Event
Please include the name of the venue and the address
Start Time
Will this event be open to the pubic or will it be a private event? *
If there are other women planning an event in your area, are you interested in collaboring with them? *
Is there any additional information that you would like to share or quesitons that you may have?
How did you find out about the National Black Woman Heal Day?
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Are there other Black women that you would like for us to connect with about hosting an event in their city?
Please provide their name and email and we will make contact or provide them with our email:
Participant Agreement *
By agreeing to host an event for the National Black Woman Heal Day, I acknowledge that Lilada’s Livingroom does not assume any responsibility for the community observance that I plan. I affirm that I and/or the organization that I represent will conduct myself/ourselves in an honoring and appropriate manner at all times. I further agree that I/we will create a safe environment that nurtures a spirit of healing, sisterhood and community. I acknowledge that including but not limited to the Founder, Committee Members, Advisory Board Members, Sponsors, etc., of Lilada’s Livingroom ( National Black Woman Heal Day) assume no liability for any loss, theft, damage, or injury to property or persons whether arising in contract, negligence, equity, or otherwise. Participation in National Black Woman Heal Day events is considered “at your own risk”.
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