Name: Address:

City: State: Zip Code:

Phone: Cell Phone:

Employment:

Church Membership:

Are you serving as a volunteer chaplain now? blank yes no Where?

How long? Years 00 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 05 04 03 02 01 Months 00 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 05 04 03 02 01

Has the facility designated you as their chaplain? blank yes no

Have you completed the Basic Volunteer Chaplain Application? blank yes no If not, please complete it now.

Go to Basic Application.

Required Training(20 Hours)

Please list classes, seminars, conferences, special courses, etc., indicating the dates and credit hours you received.

1.

2.

3.

4.

5.

References

Please complete the following reference information:

Pastor

Address

City State Zip

Phone Cell

Chaplain Friend

Address

City State Zip

Phone Cell

Director of Missions

Address

City State Zip

Phone Cell

Association

Adult Friend

Address

City State Zip

Phone Cell

Facility Employee

Address

City State Zip

Phone Cell

Deacon

Address

City State Zip

Phone Cell

CHAPLAIN'S COMMITMENT

I understand that the Volunteer Chaplain receives approval from the Chaplaincy Ministry of the Florida Baptist Convention. I will support the policies and guidelines as set forth by the State Director of Chaplaincy Ministry.

I understand that the State Director of Chaplaincy Ministries may withdraw their approval should I prove by temperment, disposition, attitude, conduct or otherwise to misrepresent the position of Volunteer Chaplain. I agree to abide by the State Director of Chaplaincy decisions related to my FBC approval as a Volunteer Chaplain.

My Response blank yes no

Signed: Date: 00 1 2 3 4 5 6 7 8 9 10 11 12 00 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 00 2007 2008