First Name
Last Name
Phone
Email
*
Address
Street Address
City
State
Postal Code
Where do you work, ex. hospital?
What is your speciality: ex. hospice?
How long have you been in practice?
Religious Affiliation
Age Group
Race Ethnicity (other is acceptable)
Would you like to join the military chaplain division of SCA?
YES
NO
Please list branch or “I am a civilian, but my service focuses on veterans.”
Do Not Forget to Attach
1. Certification
2. Proof certification is current and active - Letter or receipt or document from NACMC
Submit