Adult Jail Chaplaincy Training Application
Please complete the fields below and hit the "Submit" button at the bottom.
How did you learn about TJM's Chaplaincy Training? Choose oneWorship Team memberCurrent/former chaplainPastorWebsiteMedia itemBoard/staff memberOther
The Sheriff's Department requires a police record check for all people working in the jail system. Will you agree to a confidential release of such information?
Yes No
First Name Middle Last
Home Address
City State Zip
Business Address
Primary Telephone Home Cell Business
Secondary Telephone Home Cell Business
E-Mail Address
Date of Birth Select MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Select Day12345678910111213141516171819202122232425262728293031 Select Year19901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935
Social Security Number - - Why is this necessary?
Religious Affiliation
Ordained? No
Yes Date
Parish or Congregation
Pastor's Name Phone
Do you have clinical training and/or institutional experience?
No
Yes Briefly Describe
What are your goals as a member of the Adult Jail Chaplaincy Team?
Have you ever been convicted of a misdemeanor or felony?
Yes Check if you are currently on probation or parole?
Please list two references below:
Name Affiliation Choose oneFriendSpousePastorCo-WorkerFamily MemberCommunity MemberOther Phone
Name Affiliation Choose oneFriendSpousePastorCo-WorkerFamily memberCommunity memberOther Phone
Provide an Emergency Contact:
Name Affiliation Choose oneFriendSpousePastorCo-workerFamily memberCommunity memberOther Phone
Anything else you'd like Transforming Jail Ministries to know?
