National Association of Youth Chaplains, Inc. “Training and Certifying Practitioners to work with 21st Century Youth”

P.O. Box 90617, Staten Island, New York 10309-0617

 

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APPLICATION FOR MEMBERSHIP RENEWAL & RE-CERTIFICATION

FULL NAME: __________________________________________________________________________

PERMANENT ADDRESS: _______________________________________________________________

_______________________________________________________________________________________

PLEASE CHECK HERE IF THIS IS A CHANGE OF ADDRESS

E-MAIL: _________________________________________ CELL PH.: ___________________________

NAYC BADGE NO.: _______________ EXPIRY DATE ON NAYC ID: ______________________

RENEWING MEMBERSHIP: _____ YES _____ NO IF NO, ID & BADGE RETURNED__________

CHURCH AFFILIATION/MEMBERSHIP: ________________________________________________

TITLE/POSITION: ____________________________________________________________________

ANY CHANGES IN YOUR ORDINATION STATUS? _______________________________________

IF YES, DATE AND TYPE OF ORDINATION: _____________________________________________ (Proof of ordination should accompany this application)

ANNUAL REPORT OF WORK DONE IN THE COMMUNITY

Please provide a brief report on the work you have done in the past year in your community, including pastoral care done in any of the following settings: Please indicate sites/locations/settings.

CHURCH: _____________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HOSPITAL: ____________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HOSPICE: _____________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CORRECTIONS: _______________________________________________________________________

National Association of Youth Chaplains, Inc. “Training and Certifying Practitioners to work with 21st Century Youth”

P.O. Box 90617, Staten Island, New York 10309-0617

 

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____________________________________________________________________________________________________________________________________________________________________________________ PARA-CHURCH: _______________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide the name or names and contact numbers of persons who have supervised or can verify your work while in those settings/institutions:

Name: _________________________________________________________________________

Contact Number: ________________________________________________________________

Organization: ___________________________________________________________________

Position: _______________________________________________________________________

Name: _________________________________________________________________________

Contact Number: ________________________________________________________________

Organization: ___________________________________________________________________

Position: _______________________________________________________________________

Name: _________________________________________________________________________

Contact Number: ________________________________________________________________

Organization: ___________________________________________________________________

Position: _______________________________________________________________________

REPORT ON ONGOING COMMITMENT TO PERSONAL RECOVERY OF SOUL

Please indicate your involvement in any of the following activates designed to ensure your ongoing recovery of soul: Please indicate sites/locations/settings.

Individual or Group Counseling: _____________________________________________________

Clinical Pastoral Education (C.P.E.): __________________________________________________

________________________________________________________________________________

Spiritual Direction: ________________________________________________________________

Chapter Life/Peer Accountability Group: ______________________________________________

National Association of Youth Chaplains, Inc. “Training and Certifying Practitioners to work with 21st Century Youth”

P.O. Box 90617, Staten Island, New York 10309-0617

 

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________________________________________________________________________________

Pastoral Counseling: _______________________________________________________________

Spiritual Retreat/Sabbatical: ________________________________________________________

Other (Please describe in detail): ______________________________________________________

________________________________________________________________________________

RECORD OF CONTINUING EDUCATION FOR PROFESSIONAL DEVELOPMENT

Please list any trainings, workshops, seminars, courses completed over the past year as part of your ongoing continuing education and professional development. Please include name of organization or institution, name of course, training, workshop or seminar, and dates.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEMBERSHIP RENEWAL & RE-CERTIFICATION FEES

Annual Fees for Membership Renewal $120.00

Membership fees can be paid by check, money order, and credit card via PayPal

If you need to use PayPal please notify us by email and an invoice will be sent to you. Checks or money orders can be mailed to NAYC, PO Box 90617, Staten Island, NY, 10309-0617. Please allow a minimum of 30-45 days for your renewed ID/credential to be mailed out after receipt of your payment, for review of completed application, and approval granted by the Certification Committee, NAYC.

IF YOU DO NOT INTEND TO RENEW YOUR MEMBERSHIP OR CREDENTIAL, please notify us in writing and return your NAYC ID and badge by mail to the attention of Treasurer – NAYC, PO BOX 90617, Staten Island, NY 10309-0617.

NB: If your application for re-certification and renewal is denied, appeals can be made in writing and submitted with all supporting documentation to: The General Secretary, NAYC, PO Box 90617, Staten Island, New York, 10309-0617. The Certification committee will review all appeals and a response provided in writing within 60 days of receipt of your appeal.

FOR OFFICIAL USE ONLY

FEES PAID: ____________ METHOD: _______________ CREDENTIALS RETURNED: ___________

APPLICATION REVIEWED BY: ___________________ APPROVED:_____ DENIED:________

NEW EXPIRY DATE: _____________ SIGNATURE & DATE: _______________________________