Membership - GALEC

GALEC Membership Application

Use this form to apply for membership in GALEC. The requirements for membership are to submit annual dues and be a chaplain in training or an active chaplain in an agency. NOTE: This form is not for registration for the Chaplain training. If that is what you need, click here.

If you prefer to send the application by mail rather than online, click here.

Name(Required)

Title First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone (Home)(Required)

Phone (Cell)(Required)

Email(Required)

Enter Email Confirm Email

Agency Information

Department(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Yearly Membership

Price:

Total

Credit Card

Cardholder Name

Card Details

Phone

This field is for validation purposes and should be left unchanged.