Behavioral Health Chaplaincy Specialist Badge – Application Form
Behavioral Health Chaplaincy Specialist Badge – Application Form
SGAUS membership required. Incomplete applications will not be processed.
Date
Name
*
Name
First Name
First Name
Last Name
Last Name
Middle Initial
Personal Email
*
IE: joe.snuffy@gmail.com
Official Email
*
IE: joe.snuffy@army.mil | joe.snuffy@zulustateguard.gov
Rank
*
Spelled out – IE: Staff Sergeant (Do not include numbers, state, US, etc)
Service
Spelled out – IE: Air Force, Air National Guard, Zulu Defense Force. If not in a service: Leave Blank
Address
*
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Phone
*
I am a SGAUS Member
*
Yes
No
Military/Civilian Resume
*
Drop a file here or click to upload
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Maximum file size: 5MB
PDF Only
Letter of recommendation
*
Drop a file here or click to upload
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Maximum file size: 5MB
Letter of recommendation from a supervisor/unit commander/colleague that attests to your Chaplaincy/Behavioral Health skills.
Certificate Upload – IS-100
*
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Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-200
*
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Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-368 — (Retired) OR Ohio Dept. of Health “Disability Training” Certificate
*
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Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-700
*
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Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-800
*
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Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-505: Concepts of Religious Literacy for Emergency Management
*
Drop a file here or click to upload
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Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Psychological First Aid (PFA) course (Red Cross or equivalent)
*
Drop a file here or click to upload
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Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – License, Ordination, or Specialist Certification
*
Drop a file here or click to upload
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Maximum file size: 5MB
Upload proof of Ordination/Commission OR Professional Mental Health License. Must meet FEMA Behavioral Health Specialist requirements.
Certificate Upload – master’s degree in theology, mental health, substance abuse counseling or equivalent from an accredited college or university
*
Drop a file here or click to upload
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Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
I attest that I have passed a criminal background check and sex-offender registry check within the past 12 months.
*
I attest
I attest that I maintain current immunizations in accordance with public health and AHJ requirements for healthcare responders.
*
I attest
Current Practice Setting / Agency Affiliation
*
Please list the hospital, agency, NVOAD, or private practice where you maintain active clinical or pastoral participation.
Blue Flash
*
Yes, requesting
No, not requesting
Blue Flash – Documentation (Orders or Awards) demonstrating past activation specifically within this specialty
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Maximum file size: 5MB
Submit
If you are human, leave this field blank.