Enroll Online

To begin your Chaplaincy Program enrollment, simply fill out the online application form below.

Applicant Contact Information

First Name

Middle Initial (optional)

Last Name

Date of Birth

Street Address

City

State of

Zip

Primary Phone

Email Address

Select a Government ID

Social Security (USA)

Social Insurance Number (Canada)

Govt. ID Number (Other countries)

Social Security (USA)

Social Insurance (Canada)

Govt. ID Number (Other countries)

Applicant Work Information

Work Position

Institution/Church/Center

Field of Service where you are actively providing pastoral care that is consistent with a Christian vocation:

Street Address (Work)

City (Work)

State of (Work)

Zip (Work)

Work Phone (optional)

Pager Number (optional)

Fax (optional)

Mobile Number (optional)

Current Work Supervisor's Name, Address, and Phone Number

Faith Group Affiliation

Ordained/Licensed/Commissioned By (optional)

Place and Date (optional)

Education

College Name

College Degree and Major

College Date Completed

Seminary Name (optional)

Seminary Degree and Major

Seminary Date Completed

Graduate Institution Name (optional)

Graduate Degree and Major

Graduate Date Completed

Clinical Pastoral Education or Pastoral Counseling Training

Number of CPE Units Completed (optional)

Format: Dates / Center / Supervisor

Ministerial Experience

Church/Institution(s) / Place and Dates (optional)

Please include Church/Institution(s) / Place and Dates

Have you ever had a felony conviction?

Yes

If YES , please attach a brief description of the issue and the action taken.

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I understand the privileges, duties and responsibilities of membership in the International Christian Chaplains Association and agree to abide by its Standards and Code of Ethics. I understand that a Peer Committee will review and act upon this application, and I agree to hold such personnel, ICCA, and its officers and agents harmless with respect to action they may take in connection with such review. I understand that credentials filed in support of this application become properly of ICCA and are not returnable. I certify that the information in my application is accurate and true lo the best of my knowledge.

Payment Processing

Registration Fee

$50

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