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Application for Clergy Badge

Application for Clergy Badge

Please notice that clergy badges are issued only to applicants serving within the geographic areas where Inspira Health serves.

Before Applying, please fully read Who should apply for a Clergy Badge.

It may be helpful for you to read Clergy Badge Application Information before proceeding with this application. Many potential questions are addressed there for you.

All fields are required.  Please note that incomplete or inaccurate applications will not be processed.

These first fields are for your personal contact information, not the information for your House of worship.

All phone numbers must include area code and dashes example: 856-111-1111

Name
Address
I have read "Who should apply for a Clergy Badge" and I meet the criteria laid out in it for this application.

Information about your House of Worship

Address

Person Responsible for Clergy Badges in your House of Worship

May we send you health information by email?

Please fully read Clergy Visitation Guidelines

Please fully read HIPAA facts for Clergy

2 + 0 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

***If this is an emergency or you are experiencing chest pain, shortness of breath, or an allergic reaction, please call 911 or report to your closest Emergency Room immediately. Do not use this form for urgent medical needs.