The Clergy Badge Application Form is a document used to apply for a clergy badge. The form requests personal information, as well as information about the applicant's religious affiliation and ministry. The badge is issued by local law enforcement agencies and is used to identify members of the clergy while they are performing their duties. The form can be downloaded from the website of the state or province where the applicant resides. It must be completed and submitted to the agency sponsoring the badge. There may be a fee associated with obtaining the badge. Applicants should ensure that they meet all eligibility requirements before submitting an application. Questions about completing the form or its requirements can be directed to local law enforcement officials.
| Question | Answer |
|---|---|
| Form Name | Clergy Badge Application Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | clergy id badge, clergy id card, clergy identification card, 2008 |
CLERGY BADGE APPLICATION
Please print or type. Form must be completed in full for processing. An incomplete form may cause a delay.
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Name (As you wish it to appear on the badge) |
Title (As you wish it to appear on the badge) |
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Faith Group/Denomination |
City/State of Diocese Headquarters or Equivalent |
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Church/Synagogue/Agency
Ordained
Licensed
Lay Representative
RELIGIOUS CONGREGATION DATA
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AddressP.O. Box Number
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City, State, ZipOffice Phone Number
________________________________________________________________________________________________________
Supervisor’s Name |
Supervisor’s Phone Number |
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PERSONAL DATA |
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________________________________________________________________________________________________________
Home AddressP.O. Box Number
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City, State, ZipHome Phone Number
___________________________________________
Driver’s License Number/State Issued
Please enclose a photocopy of one of the following documents:
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Ordination certificate, call document, or license from your religious body, (in faith communities that do have regularly ordained clergy). An |
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“Authority to Solemnize Marriage License” will not be accepted as a form of documentation. |
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In the case of a ministerial student, a letter from your religious leader stating that you are functioning as a professional pastoral care provider in a |
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congregation/faith group is required. |
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In the case of a lay person or religious functioning as a professional pastoral care provider, a letter from your religious leader, congregational |
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executive committee, or religious provincial designating your professional role as a leader who is providing pastoral care to the |
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congregation/faith. |
To apply for your Clergy Badge, please follow this procedure:
1.Send this application along with your document(s), i.e., Ordination Certificate, License, or letter from your Religious Leader to the address shown below.
Do not send payment with your application.
Hospital Council of Northwest Ohio
3231 Central Park West Drive, Suite 200
Toledo, OH 43617
2.You will be notified by postcard if your application has been approved or disapproved.
3.After you have received notification (postcard) that your application has been approved, then call our office
4.Once your photo has been taken, allow two weeks for processing, and then you may call to see if your badge is ready for pickup. In addition, proof of identify is also required, such as a driver’s license or state ID card.
Cost of Clergy Badge:
1.The cost of a new Clergy Badge is $25.00 ($15.00 for a replacement badge).
2.Payment must be made by cash, money order or cashier’s check. No Personal or Business Checks accepted. If payment is made by money order or cashier’s check, please make check payable to Hospital Council of Northwest Ohio.
COMPLIANCE AGREEMENT FOR CLERGY VISITATION TO HOSPITALS
Persons wearing the Clergy Hospital Visitation Identification Badge are expected to comply with some basic guidelines for pastoral visitations. Failure to do so may result in the revocation of clergy privileges and the surrender of the Identification Badge.
1.I will comply with each hospital’s rules for visitation by clergy visitors.
2.I will wear my identification badge in a clearly visible location with the photograph exposed.
3.I will visit only members of my own religious institution, their immediate family members or persons requesting my presence.
4.I will respect the wishes of the patient who does not want a clergy visit.
5.I will not interrupt or interfere with any medical treatment or examination; I will cooperate with treatment plans.
6.I will wear the clothing, gloves, and/or masks, to eliminate passing of infection by observing the notices posted on patient’s door or asking the staff for guidance.
7.When a patient’s door is closed, I will request a member of the hospital staff to check if it is appropriate for me to visit.
8.In intensive care units, and outside regular visiting hours, I will identify myself to the staff before visiting.
9.I will limit the use of my parking privileges to my professional function as a clergy visitor.
10.I will surrender my badge and notify the Hospital Council of Northwest Ohio when I am no longer affiliated with the congregation that is identified on the badge.
11.I understand that disrespect and rudeness directed to any person at the Hospital Council of Northwest Ohio, the hospital(s), or patient(s) may result in the loss of HCNO hospital visitation privileges.
12.I agree not to disclose any information regarding any hospital patient – including that the patient is or was hospitalized, the reason for hospital treatment, or the patient’s medical condition – without express consent of the patient or, if the patient is a minor or unable to give consent, the legal guardian.
13.I have received and read the “Guidelines for Visitation and Use of the Clergy ID Badge” that accompanied this application.
14.The Pastoral Care Committee reserves the right to change the Clergy procedure as required.
Signature of Applicant |
Date |
Badge Revocation:
•The badge becomes void when the applicant leaves the congregation under which he/she applied for the badge.
•The primary clergy person may rescind badge privileges in his/her congregation by notifying the Hospital Council of Northwest Ohio in writing.
•The Hospital Council of Northwest Ohio reserves the right to revoke the security identification badge upon request of a hospital.
Appeal Process:
•Applicants may appeal a decision to the Clergy Credentialing Committee.
•All appeals must be in written form. A letter may be sent to the Clergy Credentialing Committee, in care of the Hospital Council of Northwest Ohio.
•The Committee will then review the applicant's file and render a decision.
•Should additional information be required, a meeting with the applicant may be requested.
If you have received CISM Training or other Crisis Management training, ________________, and would like to be of
assistance in the event of a disaster, please initial below.
(Please attach a copy of verification of your training/education certification).
YES, I WILL VOLUNTEER
No, I do not wish to volunteer
Revised February 25, 2008