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

  1. 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