Volunteer Chaplain Application Form

Personal Information:

Name:*

Date Of Birth:*

Home Address Street:*

City:*

State:*

Zip:*

Email:*

e.g. roy@gmail.com

Cell Phone Number:*

Denomination Affiliation:*

Current Church Position:*

How Long:*

Church:*

Address:*

Phone Number:*

Pastor:*

Educational Resume:* List Degrees Received Year

Other Credentials, Achievements, License:

Personal References (2 Required):*

Name:*

Phone Number:*

Mailing Address:*

City:*

State:*

Zip:*

Name:*

Phone Number:*

Mailing Address:*

City:*

State:*

Zip:*

Please list hospitals or healthcare centers where you have volunteered as chaplain:

Hospital or Center:

Address:

Dates of Services:

Phone:

Hospital or Center:

Address:

Dates of Services:

Phone:

Hospital or Center:

Address:

Dates of Services:

Phone:

Hospital or Center:

Address:

Dates of Services:

Phone:

Hospital or Center:

Address:

Dates of Services:

Phone:

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

Authorization And Release Form:

Name:

Volunteer Chaplain Application Form

Chaplains are available 24 hours a day, 7 days a week

Volunteer Chaplains

UC Davis Health Clinical Pastoral Education is