APT CCPE Application Digital Face Sheet

SpringFall

Name*

First NameLast Name

YesNo

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Alternate Email

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number ( if you have one )

Please enter a valid fax number.

Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Denomination/Faith Group Affiliation*

Enter your denomination/faith group here.

CME Annual Conference

Presiding Elder

If not CME, list the name of your judicatory and denominational official to whom you report:

Local Church*

Local Church Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ministry Position

Date Appointed or Assigned

Date

College Degree and Date Completed

Seminary Degree and Date Completed

Grad School Degree and Date Completed

Any Prior CPE Dates, Center and Supervisor

Denominational Reference (name/title): *

Denominational Reference's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Denominational Reference's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Denominational Reference's Email*

example@example.com

If you are a CME minister on trial or in full connection, the CCPE
office will verify your status with the Presiding Bishop.

If you are a CME local preacher or a preacher in another denomination,upload a letter stating you are in good standing from your immediate denominational supervisor (i.e., Presiding Elder, District Superintendent, Council/Convention Leader, etc.)

Personal Reference (name/relationship): *

Personal Reference's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Personal Reference's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Personal Reference's Email*

example@example.com

Narrative Responses

Response #1) Please give a reasonably full account of your life. Include, for example, significant and important persons and events, especially as they have impacted, or continue to impact, your personal growth, development, and work history. Describe your family of origin, current family relationships, and important and supportive social relationships. *

Response #2) Please give a description of your spiritual growth and development. Include, for example, the faith heritage into which you were born and describe and explain any subsequent, personal conversions, your call to ministry, religious experiences, and significant persons and events that have impacted, or continue to impact, your spiritual growth, development, and ministry context.*

Response #3) Please give a description of your place of ministry, including your role and responsibilities. If you are not the pastor, please include the name and contact information for your supervising pastor, presiding elder or other denominational official to whom you report.*

Response #4) Please give an account of a “recent ministry encounter” in which you were the person who provided pastoral care. Include the nature and extent of the encounter, your assessment of the issue(s), problem(s), situation(s). Describe how you came to be involved and what you did. Give a brief, evaluative commentary on what you did and how you believe you were able to help.*

Response #5) Please give your impressions of Clinical Pastoral Education. Indicate any learning goals or issues of which you are aware and would like to address in CPE. Finally, indicate how CPE may be able to help you meet needs generated by your ministry or call to ministry.*

YesNo

Please upload your Signed CCPE Application Packet *

Signature & Verification

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’ve certified be false. I hereby give permission to the program to which I am applying to access any prior CPE evaluations and contact previous supervisory personnel about matters pertaining to this current application, and I consent for those contacted to provide the information sought. I verify that if sending in this application electronically it constitutes my electronic signature.*

YesNo

APT CCPE Application Digital Face Sheet

References