CPE Application
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I am applying for (Check One Only):
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Certificate in Clinical Pastoral Education (CPE 100-400 or 1600 Hours).
Certificate in Supervisory Education (SEC 600-900 or 1600 hours)
Non-Certificate Student
How did you hear about CPEI?
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Personal Information
Name
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First Name
Middle Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
Race and Ethnicities.
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Profession or Ministry
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Age Grouping
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Faith Group Affiliation
Faith Group/Religious Affiliation.
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State your specific faith group, affiliation, e.g., Baptist, Methodist, Non-Denominational, other, etc.
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Ordained:
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Yes
No
Endorsed:
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Yes
No
Education
Education (Begin with High School)
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CLINICAL PASTORAL EDUCATION
Previous CPE or Supervisory CPE
REFERENCES
Identify 3 References
Clinical Pastoral Education Applicants (CPE 100-400) Complete
1. CPE APPLICANTS (1-2 Pages): Personal History. A description of one’s life story, including a description of your family of origin and current family relationships, significant events, relationships with people that have been significant, and the impact these events and relationships have had on your development.
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2.CPE APPLICANTS ONLY (1-2 Pages): Religious/Spiritual Development: A description of the development of your religious/spiritual life, including events and relationships that affected your faith and currently inform your belief system.
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3.CPE APPLICANT ONLY (1-2 Pages): Ministry Account: Describe an account you were called to help someone in need. Include the nature of the request, an assessment of the need, what actions were taken, and a summary. Students having completed a previous course/unit of CPE may include a verbatim
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4. CPE APPLICANT ONLY (1-2 Pages): What is your understanding of Clinical Pastoral Education and what do you hope to gain personally and professionally?
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5. Attach a copy of your resume.
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Supervisory Candidates Only (SEC 600-1000). Complete this Section
1. SUPERVISORY APPLICANTS ONLY (1-2 Pages): Personal History. A description of one’s life story, including a description of your family of origin and current family relationships, significant events, relationships with people that have been significant, and the impact these events and relationships have had on your development.
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2. SUPERVISORY APPLICANTS ONLY: What is your understanding of supervision education and what do you hope to gain personally and professionally?
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3. Attach a copy of your resume.
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E-Signature Required
Acknowledgement: I agree to comply: “CPEI is committed to providing an environment free from harassment and other forms of discrimination to its students, members, and credentialed persons. As such, CPEI will not tolerate harassment of any nature, which includes but is not limited to sexual harassment, unwelcome sexual advances, requests for sexual favors, and other verbal, or physical harassment of a sexual nature.” I certify that all information in this application is factually true, complete, and honestly presented. I understand that I may be subject to disciplinary action, including admission revocation or program expulsion, should the information I have certified be false. I hereby give permission to CPEI to contact my references about matters pertaining to this current application. I understand that my e-signature constitutes my signature.
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