Application for Clinical Pastoral Education
Download Application Form as PDF.
** Please note that a $10.00 non-refundable processing fee must accompany this application form. Please make cheque payable to SIPE. **
The Program for which you are applying:
Spring – intensive: ___________; Winter – extended: ____________
Preferred Site (Swan Valley, St. Paul’s Hospital, LutherCare): __________________
Full Name: _______________________________________________
Date of Birth: __________________
Present Mailing Address: ___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
E-mail address: ____________________________________________________________________________
Present Telephone Number: _________________________________________________________________
Denominational Affiliation (if applicable):
_________________________________________________________________
Present Position: ___________________________________________________________________________
Myers-Briggs Type Indicator Preferences (if known):
_________________________________________________________________
Enneagram Type (if known): _________________________________________________________________
Education: Specialization: Degree/ Diploma:
College: _______________________ _______________________ ___________________
Seminary: _____________________ _______________________ ___________________
Other: ________________________ _______________________ ___________________
Previous Supervised Pastoral Education: (including Dates, Centres and names of Supervisors):
________________________________________________________________________________________
Other Significant Education and/ or Experiences: ________________________________________________
________________________________________________
________________________________________________
Recent Positions Held: Place: Position: Dates:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
References: Name: Address: Telephone No.:
Denominational:_____________________________________________________________
Academic: _________________________________________________________________
Other: ____________________________________________________________________
What do you do for relaxation? ______________________________________________________________
Please respond to the following statements (preferably typed and double spaced):
1. A reasonably full account of your life, including important events and relationships, and the impact of these relationships on your development.
2. A description of your relationship to significant others at this time, and the issues and transitions in your life which are important.
3. A description of the development of your spiritual life, and your current spiritual care aspirations.
4. Your impression of CPE, and your expectations of the program to which you are applying.
5. Describe an incident in which you were called upon to help someone; the nature of the request and how you attempted to help.
6. Copies of your own evaluation and that of your Supervisor of previous CPE Units (if any).
_________________________________________________________
Signature of Applicant
_________________________________________________________
Date
Please forward the completed application with payment covering the processing fee to:
Brian Walton, Spiritual Care Educator
St. Paul’s Hospital, 1702 20 th Street West
Saskatoon SK S7M 0Z9
email address: brian.walton@saskatoonhealthregion.ca