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Membership Application

One Year Membership ($30)

First Name:
Last Name:
Address:
City:
State:
Zip:
Phone: ( ) -
Example: (123) 456-7890
E-mail:
How did you first hear about National Episcopal Health Ministries?
With which congregation do you minister?
Town/city:
Diocese:
   
In what capacity do you minister in this congregation? (check all that apply.)
Parish nurse Deacon
Other health professional Priest
Layperson  
   
About how many hours per week do you devote to this ministry?
Is it a paid position? Yes No
   
If you are a health professional, please indicate your professional licensure by checking all that apply.
RN Mental health counselor DC
MSW RD DO
MD Other
   
What is your highest level of education?
High School Master's Degree
Associate Degree Doctoral Degree
Bachelor's Degree  
 
Have you had education specific to health ministry or parish nursing? If so, please indicate the type:
Completed curriculum endorsed by the International Parish Nurse Resource Center
Other parish nurse/health ministry course
(number of contact hours )
   
Do you have skills that you want to offer to the wider Episcopal Church through National Episcopal Health Ministries? (Check all that apply.)
Writing for the newsletter
Teaching others about health ministries
Serving as a contact for others in your diocese
Other
   
May we add you to the Members roster on our website?
Yes No
   


National Episcopal Health Ministries
6050 N. Meridian Street
Indianapolis, Indiana 46208
317-253-1277 ext. 34
NEHM@stpaulsindy.org

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