Norton Community Hospital
100 Fifteenth Street NW
Norton, Virginia 24273
(276) 679-9774

Please enter your information below to submit your Application for Membership as a Norton Community Hospital Chaplain.

(* = Required Items)

* First Name:

Middle Name:

* Last Name:

* Address:

 

* City:

* State:

Phone (W):
(e.g... XXX-XXX-XXXX)

* Phone (H):
(e.g... XXX-XXX-XXXX)

Employer:

* Date of Birth:

   

* Email Address:

* Are you Ordained or Licensed:

* Have you served as a Hospital 
 Chaplain before:

If so, when? :
(year)

Where?:

Years of service?:

* Church Affiliation:

* Willing to a rotating call  schedule:

* In case of Emergency Contact:

* Emergency Contact Phone:
(e.g... XXX-XXX-XXXX)

List 2 References other than Family:

* Name 1:

* Phone 1:
(e.g... XXX-XXX-XXXX)

* Name 2:

* Phone 2:
(e.g... XXX-XXX-XXXX)

* 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.

BY SUBMITTING THIS YOU ARE SIGNING IT WITH YOUR NAME AS YOU ENTERED IT.

   

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