Register for Chaplaincy Program – Texas University of Theology

Legal First Name*

Last Name*

Print Name (for your Chaplain materials)* This is exactly how your name will be printed on your ID Card and Certificate.

Address* Mailing Address, City, State, and Zip Code

E-mail*

Phone 1* Required phone number format: ###-###-####

Phone 2 Required phone number format: ###-###-####

Emergency Contact PLEASE ENTER: NAME, PHONE, RELATION

Described in Step 1 & 2 of the Chaplaincy Page

Government Issued ID*

File must be a .JPG or .PNG file.

Photo for your ID Card*

File must be a .JPG or .PNG file.

Language Preference*

What is your language preference?

Sex*

Credentials*

Credentialed Ministers Please list the organization that your credentials are held with.

Are you a veteran?

Have you ever been convicted of a felony?*

If yes, please explain.

Current Occupation* Current field of work?

How did you hear about us?*

Username* Important: This will be your personal login name to access the course.

Password* Please save your password! You will have to contact our office to reset it, if you forget it.

Repeat Password* Please save the Username and Password you have selected, to access the course after your payment is complete.