American Global Christian Chaplain Association

American Global Christian Chaplain Association

American Global Christian Chaplain Association

Training Registration
Student Information
Name*

First NameMiddle NameLast NameSuffix
Birth Date *

MonthDayYear
Gender*
Ethnicity*
Email Address*
Current Residence Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
YesNo
Please provide copies of your licensing and/or ordination documents

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Church Affiliation*
Church Pastor*
Title/Position*

Emergency Contact
Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number

Payment Agreement

Total Training Cost - $600

Additional Costs for Chaplain Credentials

All Payments are NONREFUNDABLE
Per Class ($75/class)In Full ($600)
Signature*
Date*

MonthDayYear
Date
Copy of Drivers License, State Issued ID or U.S. Passport*

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