NAVAC CERTIFIED CLINICAL CHAPLAIN
NAVAC CERTIFIED CLINICAL CHAPLAIN
APPLICATION FOR NAVAC CERTIFIED CLINICAL CHAPLAIN
Name: ___________________________________________________
Mailing Address: ________________________________________________________
Work phone: ___________________________
Cell phone: __________________________
VA E-mail address:__________________________
Non- VA E-mail address:__________________________
VA Medical Center Address: ________________________________________________________
Current position or employment: ____________________________
Present association with VA
_______ Current chaplain, VA
_______ CPE Resident
_______ Retired chaplain
_______ Military chaplain
_______ Endorser
_______ Allied professional, please identify
_______ Other, please identify
DENOMINATION/FAITH GROUP AFFILIATION______________________________
ECCLESIASTICAL ENDORSEMENT YES __ NO __
DATE ____________
PASTORAL EXPERIENCE (2 years minimum required; attach additional page if needed)
CURRENT MEMBER OF NAVAC YES___ NO___
EDUCATION: DEGREE AND DATE___________________________________
COLLEGE ________________________________________________
SEMINARY ________________________________________________
GRADUATE STUDY ________________________________________________
CERTIFICATION (S)_______________________________
CLINICAL PASTORAL EDUCATION CERTIFICATION:
DATE ________ CENTER________________________
SUPERVISOR ___________________
DATE ________ CENTER________________________
SUPERVISOR ___________________
DATE _________ CENTER________________________
SUPERVISOR ___________________
DATE _________ CENTER _______________________
SUPERVISOR ___________________
BESE EQUIVALENT(S) FOR CPE
DATE ___________CENTER ________________________
SUPERVISOR ____________________
Please write a paragraph that provides your understanding of the integrating of technology used by VA (computer charting, inpatient and outpatient encounter forms/event capture, and Computerized Patient Record System – CPRS) and the delivery of quality pastoral care.
Please write a paragraph describing your experience and the use of spiritual assessments in conjunction with interdisciplinary team planning of patient treatments.
Please mail this completed application to:
NAVAC Certification Committee Chair
Chaplain David E. LeFavor, D.Min, BCC
3545 Waynesville Jamestown Road
Jamestown, Ohio 45335
Two ways to pay the $50.00 annual dues
-
Mail in Check:
NAVAC
P.O. Box 1631
Newport News, VA 23601
2. Paying by PayPal:
To make that happen for you, please use this internet link:
https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=68ZXYBQKRPPXQ
Please note: The PayPal link does say "donation", that is the only option that is available in PayPal. However, this link is secure and can also accept credit card input, or if you have a PayPal account, you can log on there. My suggestion is to log on with you PayPal account.
Questions: NAVACBCC@gmail.com