New New CPE Student Application Form

New CPE Student Application Form

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 administration@icpt.edu.

Campus

Prefix

First Name

Middle Name

Last Name

Title

Gender

Contact Address 1

Contact Address 2

City

State/Province

Zip/Postcode

Province or Territory (for non-U.S. addresses)

Home Phone

Cell 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

Other

Ethnicity

Country of Origin

Employment Information

Current Professional Position

Name of Current Employer

Address of Employer

City

State/Province/Territory

Zip Code/Postal Code

Province or Territory (for non-U.S. addresses)

Primary Work Phone

Employed from

Employed to

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

If yes, other Graduate Degree Earned

Other Graduate Degree Date Received

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

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.?

Do You Have Legal Right to Work in the U.S.?

Yes No Not Selected

Please submit verification of your legal right to work in the U.S.

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How Did You First Hear About ICPT?

Program

What Type of Unit are You Applying For?

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.

Potential Clinical Centers for CPE Units

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.

Faith Leader Referral form

Clinical Site Agreement

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.

1. Provide a reflective autobiography giving special attention to pivotal life events and relationships that have shaped you as a person.

2. Describe a situation where you helped a person in a difficult situation. Applicants with previous CPE experience can provide a case study to answer.

3. What is your understanding of CPE and what do you hope to gain in both personal and professional development?

4. Provide a brief Curriculum Vitae that describes your education, training, and work experience.

Upload Verification of highest education completed

HS Diploma, Transcript, College or Graduate Degree

5. Upload Government Issued Photo Identification

i.e. Passport, Driver's License, Military

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 $1,335. If there is going be a third party sponsor, please provide sponsors information.

Third Party Sponsor?

Corporate Name/ Sponsor Name

Phone Number

Address

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

Applicant Signature

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.

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.

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