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Chaplaincy Services and Education
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Chaplain Services
Meditation Room and All Faith Chapel
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Volunteer Chaplain application form
UC Davis Health
Chaplaincy Services and Education
Become a Volunteer Chaplain
Volunteer Chaplain Application Form
Volunteer Chaplain Application Form
Personal information
Legal name:
(required)
Preferred name (if different from legal name):
My pronouns are:
Email:
(required)
Email should be typed in the format example@email.com
Phone number:
(required)
Phone number should be typed in the format ###-###-####
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)
Phone number should be typed in the format ###-###-####
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:
Date should be typed in the format MM/DD/YYYY
Degree received:
Date received:
Date should be typed in the format MM/DD/YYYY
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)
Phone number should be typed in the format ###-###-####
Street:
(required)
City:
(required)
State:
(required)
Zip:
(required)
Personal reference (2)
Name:
(required)
Phone number:
(required)
Phone number should be typed in the format ###-###-####
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:
Phone number should be typed in the format ###-###-####
Experience (2)
Hospital or Center:
Address:
Dates of services:
Phone number:
Phone number should be typed in the format ###-###-####
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)
