Welcome to ICPT's New Student CPE 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 firstname.lastname@example.org.
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.
If you are an international applicant, you will have to obtain appropriate documentation from U.S. Immigration, which usually implies a visa and a U.S. Social Security Number. Therefore, international applicants should have such documentation approved at least six (6) months prior to the start of the program to which they are applying. If offered enrollment, can you submit verification of your legal right to work in the U.S.?
Potential Clinical Centers for CPE Units
Please list at least two (2) clinical centers in your neighborhood that you are considering using for your clinical/applied learning hours. Spiritual care visits can take place at many sites, including but not limited to: hospitals, hospices, outpatient clinics, rehabilitation centers, nursing homes, prisons, houses of worship, extended care facilities, psychiatric wards, military bases, and social service centers. If training is sponsored by your employer only one site listing is necessary.
Form and Agreement
Please download this Faith Leader Referral
form. Have your faith leader complete it, sign it in ink, and upload it.
Please download this Clinical Site Agreement
. Have your preceptor at your clinical site complete it, and sign it in ink, and upload it.
Required Supporting Information
For the following section, it is advised that you compose each of your answers below in a Word document and upload them below. Please note: documents must be in Word or PDF format only.
There is a one-time, non-refundable application fee of $75. 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 $1,235. If there is going be a third party sponsor, please provide sponsors information.
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.