Danville Regional Medical Center
Hospital Chaplain Program Application
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Church Currently Serving / Attending ________________________________________________
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EDUCATION
School - College, Seminary, and/or Graduate Studies Degree Year
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Denominational Affiliation ____________________________________________________
Ordination Date ________________ Bonding / Lincensure Date ________________
PREVIOUS CHAPLAINCY EXPERIENCE
Institution Year
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CLINICAL PASTORAL EDUCATION
CPE Center Dates Units
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Other credentials, workshops etc.
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Please tell us about your gifts of ministry which you will bring to Danville Regional Medical Center and our Chaplaincy Program -
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After approval by the DRMC Associate Chaplain's Friends of Pastoral Care, I agree to attend the Hospital Orientation Program, and in accordance with all program guidelines agree to serve as a responsible Chaplain.
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Signature of Applicant Date