Volunteer Chaplain application form

Personal information

Legal name: (required)

Preferred name (if different from legal name):

My pronouns are:

Email: (required)

Phone number: (required)

Are you over 18 years old? (required)

Yes No

Mailing address

Street: (required)

City: (required)

State: (required)

Zip: (required)

Affiliations

Faith/religious group affiliation: (required)

Current faith group involvement: (required)

How long: (required)

Religious place of service, church, mosque, temple, etc.: (required)

Address: (required)

Phone number: (required)

Leader, Pastor, Imam, Minister, etc.: (required)

Reason for wanting to volunteer at UC Davis Health:

How many hours are you available to volunteer weekly:

Educational Resume

Degree received:

Date received:

Degree received:

Date received:

Other credentials, achievements, and licenses:

Personal reference (1)

Two are required, and at least one reference from your faith group leader.

Name: (required)

Phone number: (required)

Street: (required)

City: (required)

State: (required)

Zip: (required)

Personal reference (2)

Name: (required)

Phone number: (required)

Street: (required)

City: (required)

State: (required)

Zip: (required)

Experience (1)

Please list up to the two most recent hospitals or healthcare centers where you have volunteered as a chaplain.

Hospital or Center:

Address:

Dates of services:

Phone number:

Experience (2)

Hospital or Center:

Address:

Dates of services:

Phone number:

Please state your understanding of the role of a hospital chaplain:

Authorization and Release Form:

I certify that the facts on my Chaplaincy Application are accurate and complete to the best of my knowledge. I agree and understand that any misrepresentation, falsification of information, or failure to disclose information will subject me to dismissal.

Name: (required)

Volunteer Chaplain application form

Volunteer Chaplain Application Form