Please complete this form if you are interested in submitting an application to become a volunteer associate chaplain at Wayne UNC Health Care. When finished, click " Continue" at the bottom. This application is for someone who holds an ordination, licensure, or endorsement from a recognized faith group.

Contact Information

Emergency Contact

In the event of an emergency whom should we notify?


Please list any college, seminary, or graduate studies.


Please indicate the days and times you are usually available to volunteer.

Pastoral Experience

Please list any pastoral counseling experience or clinical pastoral education.


Please list denominational affiliation, ordination date, or licensure date.


Please list your current or most recent employer, if applicable.


Please use references who have known you at least one year. Do not use physicians, relatives, or roommates. References from those individuals will not be accepted.

Current Church

Please list the current church you are serving or attending.


Please list any relatives or friends who work at Wayne UNC.

Work History

Have you ever been dismissed or forced to resign from any job or volunteer position? If yes, please explain.

Current Date

I Agree

I understand and agree that submitting this application form does not automatically register me as a Wayne UNC Health Care volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering. By submitting this form, I attest that the information I have provided on the form is true and accurate.