PCN Membership Form
Thank you for promoting excellence in pediatric spiritual care through your individual membership in PCN!

The Pediatric Chaplains Network is the premier professional organization for pediatric chaplains in North America. It is a volunteer-led 501(c)(3) organization dedicated to enhancing the spiritual care of children and families in healthcare. Membership in the PCN is open to pediatric chaplains and others interested in promoting the spiritual care of children and families in healthcare.

As a member of the Pediatric Chaplains Network you will:
♣ partner with others to support the PCN’s mission to provide continuing education, promote spiritual care research, and enhance collaboration and mutual support among chaplains;
♣ gain access to the Members Only section of the PCN website;
♣ receive a discounted registration fee for the annual PCN National Conference;
♣ have voting privileges at the annual PCN Business Meeting;
♣ be eligible for election to leadership positions in the organization.

Membership in the PCN is open to pediatric chaplains and others interested in promoting the spiritual care of children and families in healthcare.

Membership dues for calendar year 2018:
-- Individual Membership: $75
-- Individual Membership (Retired): $35
-- Individual Membership (Student): $35
Note: Reduced individual membership dues are available to persons fully retired from a career in pediatric chaplaincy and for students enrolled full-time in an accredited CPE residency.

Thank you once again for your interest and support of the Pediatric Chaplains Network!

(Please scroll down on this form, not the webpage, to enter your information.)

Title
Your answer
First Name *
Your answer
Last Name *
Your answer
Preferred Pronouns
Hospital or Institution *
Your answer
City and State of Institution
City, ST (i.e. Houston, TX)
Your answer
Preferred Street Address *
Your answer
City *
Your answer
State/Province *
Zip Code *
Your answer
Preferred Email *
Please enter the email you would like to use for contact.
Your answer
Phone (Preferred) *
(xxx) xxx-xxxx
Your answer
Work Phone
(xxx) xxx-xxxx
Your answer
International Mailing Information
Your answer
Religious / Denominational Affiliation
Your answer
Certifying Body *
Area of Specialization *
Required
I wish to be added to Google Group listserv. *
The Google Group is our network’s way of communicating with one another, providing an opportunity to enhance ministry and support each other. If you click yes, we will add you to that membership with your preferred email. If you would like more infomation about the listserv, please visit http://bit.ly/pcnlistserv
Required
I want to be included in the PCN Directory for the 2018 National Conference and give permission to use my information for this purpose alone. *
If you click ‘yes,’ we will use your photo taken at last year’s conference, unless you were not present or wish to provide a different picture. If you did not provide a photo last year, please email a simple portrait picture (from your phone even!) to Jennifer Prechter at jennifer.prechter@orlandohealth.com.
Required
I want to be contacted by PCN about education opportunities. *
Please share any additional information you believe we may find helpful.
Your answer
How are you paying? *
Membership dues are $75 for 2018, $35 for a retired or student individual membership. Pay online  OR, send a check payable to PCN, to Pediatric Chaplains Network, P.O. Box 1664, Belton, TX 76513. Please write "2018 Membership" in the memo line.
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