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


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



Please forward the completed application with payment covering the processing fee to:

Margaret McCallum , Spiritual Care Educator


Box 27

Kenville, Manitoba

email address: [email protected]