Chaplain Fellowship Ministries
4410 Box Canyon Drive
Temple, TX 76502-3263

DISASTER RESPONSE CERTIFICATION APPLICATION

Print clearly or type your information, you can also attach an address label if you have one! Please take your time and read everything on this application carefully. Documents will be sent to the address you list below, please make sure you list the address where you want your documents to be sent. This certification program is an independant certification program for individuals seeking certification in Disaster Response.

PLEASE NOTE: Chaplain Fellowship Ministries and Homeland Crisis Institute does not deploy chaplains to disasters areas. Chaplain Fellowship Ministries and Homeland Crisis Institute does reinburse chaplains for expenses when they self deploying.

Applications must be mailed. Cannot be sent by e-mail or fax. This application prints out better in Landscape format. Please type or print clearly, if you have an address label you can attach it to the application


Name: ___________________________________________________ Date: ______________________

Address: ____________________________________________________________________________

City: ___________________________________ State: ______________ Zip Code: ________________

Home Phone (____) ________________________ Business Phone (___)_________________________

E-mail Address: ______________________________________________________________________

Date of Birth: ________________________ Age: _______________ Sex: ________________________

Marital Status: [     ] Single [     ] Married [     ] Divorced [     ] Remarried [     ] Other

Hair Color: _____________ Eye Color: _______________ Height: ____________

Current Driver License or State ID #: ____________________________ State: ____________________

CFMI ID Card No: _________________________

Emergency contact information and any major health problems you may have will be encoded in the magnetic strip on the back of your ID Card. This has helped save several member's lives involved in accidents.

In Case of an emergency notify: _______________________________________________________ Relationship: ____________________________________ Phone: _________________________________

Health Problems: Heart Disease: _______ High Blood Pressure: _________ Diabetes: ________ Other: ___________________________________________________________________________________

PLEASE READ EVERYTHING ON THIS APPLICATION FOR CERTIFICATION CAREFULLY


Please Read Carefully: Make sure you read this application for certification very carefully before signing. No application for certification will be considered or processed without this application being completely filled out, signed, dated and copies of all the required documents have been submitted.

Certification requirements: Copies of the following certifications and certificates must be sent with your application for certification.

1. IS-230.b Fundamentals of Emergency Management

2. IS-800.B National Response Framework, An Introduction

3. IS-907 Active Shooter: What You Can Do

4. IS-100.SCa Introduction to the Incident Command System for Schools

5. IS-700a National Incident Management System (NIMS)

6. IS-5.a An Introduction to Hazardous Materials "WMD"

7. IS-368: Including People With Disabilities & Others With Access & Functional Needs in Disaster Operations

8. IS-366.A: Planning for the Needs of Children in Disasters

9. HCI01021998 Will help to better understand how to effectively communicate as a disaster relief chaplain.

10. Required to be Certified in CPR and CPR First Aid:

11. Two Passport Photos: Not a copy of your passport or scanned photos. Passport photos must have a white background, nothing else will be accepted, ID Card will not be issued unless this requirement is meet.


CERTIFICATION FEE FOR PROCESSING IS $65.00: Certification may take up to 2 to 3 weeks for delivery once application has been received and approved. Your certification will include the follolwing!

1. Certification Certificate: ( Certifications are issued through HomeLand Crisis Institute, the training division of Chaplain Fellowship Ministries International Inc.

2. Clip on vertical ID Card a 30 mil plastic ID Card with 25 holograph seals of authenticity on the front and back.

Checks or Money Orders: All donations must be in US funds. Make payable to: Chaplain Fellowship Ministries, Mail your completed application with your check or money order to the address at the of this page. Checks must clear our bank before documents will be processed.

Major Credit Cards: You can make your donation using your major credit card by clicking on the donation button below. Mail your completed application to the address at the top of this page after you make your donation. Application must be sent in for processing within 30 Days from the date your certification fee was made through PayPal.

I hereby certify that I am the person who has taken the above required courses of instrucrion for certification in disaster response.

 

Signature Is Required: ______________________________________________________ (Required)


FOR OFFICIAL OFFICE USE ONLY

Date Application for certification was received: ________________

Date Application for certification was reviewed: ________________

Application Approved by: ________________________________

Date Approved: _______________________________________

Date Disapproved: ____________________________________

CFMI Member's ID No: _________________________________

Chaplain Fellowship Ministries is a faith based Christian Ministry legally incorporated as a Nonprofit public charity with Chaplains and Ministers serving Nationwide. The information required within this application shall be subject to change without notice. Chaplain Fellowship Ministries reserves the right to refuse certification to any applicant or member by directive of the board of directors of Chaplain Fellowship Ministries. All decisions made by the board of directors shall be binding and final.