Application for Membership
Norton Community Hospital Chaplain
100 Fifteenth Street NW
Norton, Virginia 24273
276/679-9004
Name_________________________________________________________________________________
Address_______________________________________________________________________________
Telephone (H) _____________________ Age____________ Date of Birth ______________________
(W)
____________________ Employer___________________________________________
E-mail address ________________________________________________________________________
Are You Ordained or Licensed?
___________________________________________________________
Have you served as a hospital chaplain before?
____________________When_____________________ Where________________________________________ Years of Service__________________________ Church Affiliation ______________________________________________________________________
Are you willing to serve on a rotating call
schedule?__________________________________________
In Case of Emergency Contact:
__________________________________Phone___________________
List 2 References: Name_________________________________
Phone:__________________________
Name_________________________________ Phone:__________________________
Why do you believe a hospital chaplaincy program is
important?_________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I hereby make application
for membership in the Norton Community Hospital Chaplaincy Program. I
agree to
Uphold the purpose, policies and procedures of the chaplains and the
institution that it serves. I understand that
Membership is contingent upon completion of orientation, PPD, and criminal
record background check.
Membership is renewed upon my completion of an annual orientation and PPD.
A copy of my ordination certificate or licensure is attached.
__________________________________________ _______________
Signature Date
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