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. Payment must by made by cheque or money order made 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: ___________________________________________________________________________

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: Please include the Name, Address, and Telephone No. – Provide each reference with the reference form found on the website and have them send it directly to the Registrar

Denominational:_____________________________________________________________

Academic: _________________________________________________________________

Other: ____________________________________________________________________

Please attach to this application your type written response to the following: (total pages not to exceed 8 pages):

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:

Margaret McCallum , Spiritual Care Educator

Registrar

Box 27

Kenville, Manitoba

email address: [email protected]