Student Application

First Name

Last Name

Date of Birth

Phone

Organization Name

City and State

Position

Dates of Employment

School

City and State

Degree Awarded

Dates of Attendance

Denomination/Church

Are you a U.S. citizen? Required

Yes

Have you even been convicted of a felony or misdemeanor? Required

Yes

Are you ordaind/licensed?

Yes

If yes, year ordained

If yes, please explain:

Pastoral/Church Contact Name

Position

Phone Number

Family Member Name

Relationship

Phone Number

Personal Reference Name

Relationship

Phone Number

Please explain how 1 Cor 1:26-31 relates to you and your call to the chaplaincy:

Please provide a brief autobiography, including pivotal life events and relationships that have shaped you as a person:

Please describe a situation when you helped another person who was facing a difficult life situation, including your intervention and the outcome:

I acknowledge that I have read and agree to the Statement of Faith, Code of Contact, and Requirements for ICA Chaplains.