Application for Clinical Pastoral Education	APPLICATION FOR:
Association for Clinical Pastoral	_____ Winter _____ Fall
Education, Inc.	_____ Spring _____ Extended
	_____ Summer _____ Year
	Earliest date you can begin: ___________ Seminary Credit Yes No

Name ___________________________________________ E-mail ___________________________

Present Mailing Address _______________________________________________________________

Home Phone (_____) _______________________ Office Phone (_____) ________________________

Permanent Address __________________________________________________________________

Denomination/Faith Group Affiliation ______________________________________________________

Association, Conference, Diocese, Presbytery, Synod ___________________________________________

Present Position _______________________________ Ordained? __________ Date ______________

EDUCATION: DEGREE:

College _______________________________________ ________________________________

Seminary _____________________________________ ________________________________

Graduate Study ________________________________ ________________________________

PREVIOUS CLINICAL PASTORAL EDUCATION:

Dates Center Supervisor

____________________ ________________________ ____________________________

____________________ ________________________ ____________________________

____________________ ________________________ ____________________________

Form #1—rev. 1996

REFERENCES AND ADDRESSES:

Denomination/Faith Group _____________________________________________________________

______________________________________ Telephone (_____) ____________________________

address

Academic _________________________________________________________________________

______________________________________ Telephone (_____) ____________________________

address

Other ____________________________________________________________________________

______________________________________ Telephone (_____) ____________________________

address

ATTACH TO APPLICATION:

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 summery prepared by an ACPE supervisor or another person satisfactory to the center to which you are applying. If the written summery is not yet available, please indicate the following:

Admission interview conducted by ________________________________________________________

Address _______________________________________________ Zip Code ____________________

Telephone (_____) __________________________ Date interview conducted _____________________

THOSE WITH PREVIOUS CPE SHOULD COMPLETE THE FOLLOWING:*

8. Copies of previous CPE evaluations written by you and your supervisor.

9. 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.

Signature of Applicant _________________________________________________________________

Date _____________________________ Social Security # ___________________________________

Send this application directly to the CENTER or CLUSTER to which you are applying.