Please fill out your name as it appears on your government issued ID

If you’ve answered YES to any of the above questions, please provide details including date, location, arresting agency, charge, and disposition, where applicable:

By giving my authorization below, NYSCG and its affiliates are hereby allowed to carry out a standard check of law enforcement records, which may contain information on any charges, prosecutions, or convictions related to criminal or civil charges.

• I understand that this check is only for the purpose of the NYSCG application process, and my consent will be valid indefinitely.
• I understand that any data obtained as a result of this check will be used solely for the purpose of determining clearance for NYSCG volunteering.
• I understand that there is no assurance of my entry into NYSCG and the decision rests completely with them.

I acknowledge that the credentials, apparel, and vehicle identification placard issued to me by NYSCG and its affiliates are only for the purpose of verifying my identity as a member of a private, non-profit, volunteer association.

I understand that I do not hold any State employment or position. In case of any wrongful use of the credentials, apparel, and vehicle identification placard on my part, it will result in the immediate end of my membership; thus, I will have to return all of the credentials distributed or owned by NYSCG and its partners right away.

On my own accord, I agree to comply with all the rules and regulations set by NYSCG and its affiliates, provided either verbally or in writing, or available from their website, which may be updated without prior notice.

I openly accept that any violation of these aforementioned rules and membership obligations, as well as any conduct unsuitable for a spiritual care provider, can lead to the immediate termination of my association with the organization.

I understand that should I be dismissed or if I abandon or neglect to renew my membership, I am responsible for returning both my badge/shield, ID card, and/or vehicle identification placard to NYSCG or facing legal action to the utmost extent permissible by law.

I agree not to hold NYSCG nor any of its representatives responsible for the improper use of the credentials, apparel, and vehicle identification placard given, purchased, and/or owned by NYSCG or due to any physical, mental, and/or emotional damage that I may endure while carrying out my duties as a staff or volunteer chaplain or at another moment.

I understand that wrongful use of the credentials, apparel, and vehicle identification placard distributed to me by NYSCG or any misrepresentation or violation on my part may result in corrective measures, including potential suspension from the organization and associates, legal action and even criminal accusations which can possibly end up with imprisonment.

I understand that signed applications belonging to NYSCG as well as any accompanying documents will remain its property and not be returned. It will be destroyed upon resignation or discharge from NYSCG.

I understand that no tuition refund will be given after the first day of class. I am aware of my responsibility to read and comprehend the regulations established within this document and on the NYSCG website. I recognize and accept all mentioned statements made here in the Agreement Certificate above. I attest that I am of sound mind, and I voluntarily give my signature along with today's date as evidence that I concur with all declared matters.

1. Adhere to and familiarise yourself with all rules and regulations of NYSCG, both verbal and written.

2. Respect the guidelines created by any public or private institution.

3. Insubordination will not be tolerated in any form and is grounds for immediate termination.

4. Inappropriate behavior, including negative conduct towards people, co-workers, and authorities, that does not reflect well on a chaplain is also cause for instant dismissal.

5. Do not assume anything without first verifying it.

6. Please uphold a reputable image.

7. Do not use credentials if undergoing disciplinary action by ecclesiastical authority.

8. Alert NYSCG immediately should you commit any legal actions contrary to regulations.

9. All NYSCG insignias such as credentials, badges, or placards are solely owned by NYSCG and must be instantly returned in the instance of resignation or when membership expires.

10. A minimum of one activity report should be turned in monthly unless unforeseen circumstances prevent you.

11. Membership may be revoked if guilty of a legal violation or knowingly providing false data.

12. IDs and certifications must be up to date.

13. You must adequately identify yourself to the authorities if necessary or requested.

14. Shields can only be used in conjunction with a valid ID card. Your ID card can be used on its own.

15. Shields may never be displayed on a vehicle dashboard. Violation of this rule warrants an instant discharge.

16. Immediately report lost/stolen documents to the local police station. You must hand in a copy of the report to NYSCG.

17. NYSCG licenses and provides replacement badges for a fee.

18. Do not misuse your credentials. Your shields are not to be shown to law enforcement officers in an inappropriate manner.

19. Do not represent NYSCG without authorization when talking to media, press, or officials.

20Never change any part of your credentials

22. Expired credentials may not be used.

23. Abstain from using your credentials to get favors, free travel, and definitely not trespass.

23. Dress appropriately when presenting as a chaplain.

24. Immediately respond to NYSCG when contacted, or notify NYSCG as soon as possible if you cannot respond.

25. Follow the guidelines mentioned on the back of the vehicle identification placard- misuse may lead to dismissal.

26. Lights and/or sirens may never be attributed to NYSCG and can only be used if approved by the police department, fire department, and/or ambulance corp.

27. Annual memberships are given for an annual fee, which includes a new ID card.

28. Set up an appropriate email and voicemail message.

29. Never make any derogatory comments about other chaplains or members. Disputes should be settled peacefully between those involved; contact a NYSCG supervisor if mediation is necessary.

I fully understand and accept the Rules and Regulations mentioned above. I attest that I am of sound mind, and I voluntarily give my signature along with today's date as evidence that I concur with all declared matters.

I acknowledge that the Badge/Shield issued to me by NYSCG is its property and must be given back upon the end of my membership or resignation. In the event of my failure to do so, NYSCG reserves the right to lodge a complaint with state or local law enforcement. Abusing or exploiting these credentials or engaging in inappropriate activities may result in disciplinary sanctions up to and including dismissal from NYSCG and its associates, legal action, and criminal culpability culminating in imprisonment.

I hereby agree to and understand the content of this licensing document. I attest that I am of sound mind, and by signing with my name in print, affixing my signature, including today's date, and providing any other information needed, I do so freely and willingly under my own volition.

I solemnly affirm that I shall serve God and humanity to the best of my abilities according to the principles of compassion, service, and respect. As a chaplain, I must be prepared to work in diverse environments with colleagues who may have different beliefs than my own. To this end, I agree to uphold the NYSCG and the United States Code of Ethics for Chaplains and take responsibility for adherence to their provisions.