I am a Christian Healthcare Professional in a physical, mental and/or spiritual healthcare discipline who has academic and professional preparation with appropriate degrees, licensure, certification, or a student in a graduate healthcare degree program preparing for a professional degree, and/or a lay person (associate) committed to the healing ministry of Jesus.

  I am committed to Jesus Christ and His Spirit and open to integrating His teaching and healing into my life and my healthcare work and/or ministry. I am committed to my own healing and to growing in the gifts of the Holy Spirit.

Application for Membership

Name: Date :
Title:  
Degrees:

Specialization:
Religious Affiliation:
Birthdate :

Please Check your Specialty Group: Physicians/Dentists/Chiropractors; 
Psychotherapists; Clergy and Religious; Nurses;  Allied Health;
Pastoral Care; Educators; Associates;
Healthcare Institutions/Centers

Addresses: (Provide both - check one to indicate mailing preference)
Home
Address:
City:  
State:   Zipcode:  
Country:
Phone:
Email:
Fax:

Work
Employer / Address:
City:  
State:   Zipcode:  
Country:
Phone:
Email:
Fax:

Educational Background: (Beginning with most recent)
Please list Institution, Degree/Diploma, Department, Date


Student   Current Full Time Student?     Yes      No  
Where?:
 
Expected date of Graduation:    
Degree/License Expected:
 

Professional and/or Work Experience: (Beginning with most recent)
Please list Organization, Position Held, Date



Gifts, Ministries, Skills, Hobbies, Interests (please check as many as apply to you):

ADVERTIZING
MEMBERSHIP CONCERNS
PUBLIC RELATIONS/COMMUNICATIONS
SPEAKING/PRESENTING/TEACHING
FINANCE
WEB SITE
SPIRITUAL LIFE
PUBLISHING
PROGRAM DEVELOPMENT
RESEARCH
ECUMENISM
HEALING PRAYER
MARKETING
FINANCE
FUND RAISING
OTHER:

Memberships in Professional, Civic & Christian Organizations:

Publications Authored: (If applicable: those most recent and/or relevant to ACT membership; If not applicable type in "none" below.)
Journal Articles, Books, Videos, CDs or Audio Tapes



Languages:: (List in order of fluency)
Written:

Spoken:

Spiritual Life:  What do you see as important in your spiritual growth and development? What resources do you use to continue to grow spiritually? Please check as many as apply to you.

Daily prayer time
Personal Bible study
Attending church services
Spiritual direction
Participation in healing services
Prayer group participation
Group Bible study
Sacraments
Retreats
Charismatic renewal
Other:


References:  (list at least one) Clergy, ACT Member, Professional Colleague

Name:
Phone: