Mountain States Health Alliance
Department of Pastoral Care

Volunteer Chaplaincy Association Application

Please select the facilities you would like to serve:









 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Ordained:


Licensed:


 
 
Education:

Highest Grade Completed:
















 

This affirms that all information above is correct and that I have read and will abide by the guidelines set for visitation at Mountain States Health Alliance facilities. I recognize that any badges/keys or handbooks issued are property of Mountain States Health Alliance and will return all items when no longer serving in this area or will update the ID badge when need indicates.

I agree:


 
 

List any prior hospital voluneer work experience: