Application for Clinical Pastoral Education
 
required
 Indicates the information is required.
  Application is for: Winter
Spring
Summer
Fall
Extended
Year
  Earliest Date you
can begin:		 Month Day
   
required
First Name: 
M.I.
required
required
 Address: 
  Address 2:
required
City:
required State:
required
 Zip:
required
Phone:
 - -
required E-mail:
required
Confirm E-mail:
  Denomination/
Faith Group
  Association, Conference, Diocese, Presbytery,
Synod
  Present Position:
  Ordained:
Date:
  EDUCATION  
  College
  Seminary
  Graduate Study
     
  PREVIOUS CLINICAL PASTORAL EDUCATION
  Dates Center Supervisor
 
 
 
     
  REFERENCES AND ADDRESSES
  Denomination/Faith Group
  City/State/Zip
  Telephone - -
  Academic
     
  Denomination/Faith Group
  City/State/Zip
  Telephone - -
     
  Other
  City/State/Zip
  Telephone - -
     
 

PLEASE ATTACH THE FOLLOWING TO YOUR APPLICATION:

Upload a Word file here

  1. A reasonably full account of your life, including important events, relationships with people who have been significant to you, and the impact these events and relationships have had on your development. Describe your family of origin, your current family relationships and your educational growth dynamics.
  2. A description of the development of your religious life, including events and relationships that affected your faith
    and currently inform your belief systems.
  3. A description of the development of your work (vocation) history, including a chronological list of positions and
    dates.
  4. An account of an incident in which you were called to help someone, including the nature of the request, your assessment of the "problem", what you did, and a summary evaluation. If you have had previous CPE, include this information in verbatim form.
  5. Your impression of Clinical Pastoral Education and your educational goals, including how this training will be used to meet your goals for doing ministry.
  6. Application fee if required by center.
  7. Admissions Interview: If you are not being interviewed at the center to which you are applying, you will need to obtain an admissions interview summary prepared by an ACPE supervisor or another person satisfactory to the center to which you are applying. If the written summary is not yet available, please indicate the following:

Admission Interview conducted by:

Address:

Telephone : - -

Date Interview Conducted :

THOSE WITH PREVIOUS CPE SHOULD COMPLETE THE FOLLOWING: *
 1. Copies of previous CPE evaluations written by you and your supervisor.
2. What are your personal and professional goals and how will continued training aid that process?
*PLEASE NOTE: CPE Residency programs usually require an in-person interview in their admissions process

Date

Social Security Number : - -