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

First

Last

Telephone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Cell phone number

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

Yes

YOUR Position/Title

While your clergy badge gives you privileges network wide it is important to us that we know the PRIMARY place you will visit. Please select which Medical Center will be your PRIMARY place of visitation:

Elmer

Mullica Hill

Vineland

Woodbury

Bridgeton

Mannington

Information about your House of Worship

House of Worship

Senior leader

Title

Address

Address 2

City/Town

State

ZIP Code

Telephone

Person Responsible for Clergy Badges in your House of Worship

Name

Title

Telephone

May we send you health information by email?

Yes

Please fully read Clergy Visitation Guidelines.

Type your name as your signature to confirm reading and agreement with these guidelines.

Please fully read HIPAA facts for Clergy.

Type your name as your signature to confirm reading and agreement with these guidelines.

Denominational affiliation you want listed on your badge

CAPTCHA

Math question 4 + 13 =

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.