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CPE Application Form

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Please print this page, complete your personal information and use as many extra pages as neccessary to answer the essay questions.

Send your signed application fact sheet, attachments and fee (payable to Emanuel ACPE) to:

The Rev. Frederick G.A. Sickert
Legacy Emanuel Medical Center
Spiritual Care and Education
2801 N. Gantenbein
Portland, OR 97227

Application for (please check)

__Fall
__Winter
__Spring
__Summer

__Extended
__Single
__Residency

First name
Last name

Present mailing address
Street / P.O. Box
City   State   Zip

Permanent address
Street / P.O. Box
City   State   Zip
Email
Phone   Fax

Denomination/Faith Group Affiliation:
Name
Association, Conference, Diocese, Presbyter, Synod
Present Position Ordained?__Yes__No   Date

EDUCATION:

High School	Degree:	Dates:
College	Degree:	Dates:
Seminary	Degree:	Dates:
Graduate	Degree:	Dates:

PREVIOUS CLINICAL PASTORAL EDUCATION:

Dates	Center	Supervisor

REFERENCES AND ADDRESSES:

Denomination/Faith Group
Name
Street / P.O. Box
City   State   Zip
Phone

Academic
Name
Street / P.O. Box
City   State   Zip
Phone

Other
Name
Street / P.O. Box
City   State   Zip
Phone

ESSAY QUESTIONS:

Please take your time in writing out your responses to the questions below.

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.
A description of the development of your religious life, including events and relationships that affected your faith and currently inform your belief systems.
A description of the development of your work (vocation) history, including a chronological list of positions and dates.
An account of an incident in which you were called to help someone, including the nature of the request, your assessment of the "problem," and what you did, and a summary evaluation. If you have had previous CPE, include this information in verbatim form.
Your impression of Clinical Pastoral Education and your educational goals, including how this training will be used to meet your goals for doing ministry.
Send copies of previous CPE evaluations, if any, written by you and your supervisor.
What was the most significant learning experience in previous CPE and how have you continued to work in the learning method? Illustrate your strengths and weaknesses as a professional person.
For summer unit students and residency applications, arrange an admissions interview by an ACPE Supervisor or another qualified person. (CPE Supervisors, Seminary Liaison Professors and Regional Directors may recommend interviewer). Include the interview in your application materials, or ask the interviewer to forward it by email.
What are your personal and professional goals and how will continued training aid that process?

Signature of applicant
Date
Social Security No.

Last updated: May 25, 2010

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