New Supervisor-In-Training Student Application Form

Supervisor-In-Training Student Application Form

Welcome to ICPT's Supervisor-In-Training Application Form.

You can save your application at any time you wish and return back to it at a later time.
If you have any questions about the application and enrollment process, please contact administration@icpt.edu.

Campus

Prefix

First Name

Middle Name

Last Name

Title

Gender

Social Security No

Contact Address 1

Contact Address 2

City

State/Province

Zip/Postcode

Cell Phone

Home Phone

Birth Date

ICPT seeks to train students from all racial and ethnic groups in our society. Please indicate any identities in which you would include yourself. Any disclosure of ethnic background is completely voluntary and optional, and omitting or providing answers will not affect consideration of your application. This information is used solely for compliance with civil rights laws. ICPT does not discriminate in its admissions decisions on the basis of race, color, religion, gender, sexual orientation, national origin, age, marital status, or disability.

Faith Group Affiliation / Denomination

Ethnicity

Country of Origin

Employment Information

Current Professional Position

Name of Current Employer

Address of Employer

City

State/Province/Territory

Zip Code/Postal Code

Primary Work Phone

Dates of Employment

Are You Ordained/
Professed/Commissioned?

If yes, Give Date Since

Educational Background

Are You a High School Graduate?

Yes No Not Selected

If yes, date of High School Graduation

Did You Graduate from College/University?

Yes No Not Selected

If yes, date of College/University Graduation

College/University Degree Earned

Major

Did You Graduate from Seminary?

Yes No Not Selected

If yes, name of Seminary

Seminary Degree Earned

Date of Seminary Degree Received

Do You Have Other Graduate Studies?

Yes No Not Selected

Do you have prior dates of CPE training and/or Supervisory experience, if any.

Please create a word document and limit your answer to 500 characters.

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Have you ever been convicted or pled guilty to a misdemeanor, felony, or other crime?

Yes No Not Selected

If yes, please explain

Are You an International Applicant?

Yes No Not Selected

How Did You First Hear About ICPT?

What Type of Unit are You Applying For?

Emergency Contact Info

To support student safety and program responsibilities, all applicants are required to provide emergency contact information. This information will be used only if a situation arises in which the student cannot be reached directly and immediate contact is necessary. Please provide an appropriate emergency contact. Applicants are responsible for ensuring that this information is accurate and kept current throughout their enrollment.

Contact Name

Relationship

Home Phone

Work Phone

Cell Phone

When would you like to start training?

When would you like to start your training?The following schedules are available for SIT training. New session schedules will be posted as they become available. For corporate clients seeking customized corporate training schedules, please contact ICPT at administration@icpt.edu.

Program

Enroll In

Required Supporting Documentation

1.Documentation of Board Certification status by a COMISS-recognized organization

2.Two-three page paper outlining reasons for wanting to be considered for the SIT program

3.Three-five page paper defining theory of supervision of Clinical Pastoral Education

4.Documentation showing completion of a minimum of 4 units of CPE

5.Evidence experience in the field and proof of a Master of Divinity or a Masters, or Doctoral (or equivalent) degree in theology, counseling, or related discipline from an accredited school

Faith Leader Referral Form

Please download this Faith Leader Referral form. Have your faith leader complete it, sign it in ink, and upload it.

5. Provide a Faith Leader Referral.

Veterans Affairs (VA) Applicants Only

Veterans Affairs (VA) Additional Documentation Requirement: The U.S. Department of Veterans Affairs (VA) requires ICPT to collect additional documentation from applicants training at VA clinical sites. This requirement applies only to VA applicants only. VA applicants must submit the following additional documentation: Primary and secondary forms of identification (see: https://www.va.gov/files/2024-04/Acceptable%20Forms%20of%20ID.pdf). Proof of U.S. Selective Service Registration, either a Registration Letter or a Status Information Letter (available at https://www.sss.gov ). A copy of your faith group endorsement for VA chaplaincy Please email these documents to help@icpt.edu . In the body of the email, include: Your full name and contact information; Date of application; VA medical center with which you are affiliated; Name of the VA ICPT CPE Educator. Your application will not be considered complete until all required VA documentation has been received. Applicants who are not applying to a VA clinical site may disregard this section.

Application Fee

There is a one-time, non-refundable application fee of $150. Once your application and enrollment agreement are approved you must remit tuition in full two weeks prior to the start of the unit unless payment arrangements have been made. The tuition for the unit is $1,435. If there is a third party sponsor, please provide their information. Please note, for third party sponsorship, the appropriate signed paperwork must be on file prior to the start of the unit.

Third Party Sponsor?

Corporate Name/ Sponsor Name

Phone Number

Address

I understand that there is a one-time, non-refundable application fee

HOW TO ADD YOUR SIGNATURE:

** If your device has a touch-screen, you can use your finger to sign this document. If you are using a non-touch screen, you can use your mouse to sign this document.
For any reason, if you are unable to sign electronic signature please type in your name. The typed in name will be considered as an electronic signature.

Applicant Signature

Student Signature Date

Date Signed

Full Name

For any reason, if you are unable to sign electronic signature please type in your name. The typed in name will be considered as an electronic signature.

I certify that all the 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 ICPT to which I am applying to access my 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 am aware that my application materials will be read by professionals involved in the admission process, accreditors and other regulatory agencies in addition to a Clinical Pastoral Education supervisor. I verify that in sending this application electronically it constitutes as an understanding of my electronic signature. By signing this agreement, I attest to reading and understanding the following ICPT Admissions and Enrollment Requirements:

- Applicants must be able to read, write, speak, and understand English.

- Applicants must be 18 or older.

- Applicants must have a bachelor's degree, or greater, from an accredited college or university and a minimum of two (2) years of ministerial experience or applicable professional experience.

- Applicants without a bachelor's degree must have a minimum five (5) years of ministry experience or applicable professional experience.

- Applicants must be willing to adhere to their own faith tradition and be willing to learn with those of faith traditions other than their own.

- Applicants must possess the ability to minister to persons in various emotional states. - Applicants must be willing to learn from others and be able to communicate effectively to those who possess different values without proselytizing or evangelizing.

- Applicants must have his/her own transportation to get to and from unit sessions/clinical sites.

- Applicants must adhere to the policies and procedures at their clinical site and/or place of ministry including, but not limited to, working in a smoke-free environment.

- I have downloaded and read the Student Handbook at http://www.clinicalpastoraled.org/enroll.html or received a copy from ICPT administrators.

- I have read the current ICPT Student Handbook.

- I have read, understood, and received a copy of this completed and executed application.

Enter the above code

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