APPENDIX 8

ATTESTATION OF GOOD STANDING

Note: all documentation must be submitted at the same time. Incomplete submissions will not be considered.

In preparation for a Readiness Consultation, documentation of the following formal requirements must be submitted for Appendix 8 to be signed by the ACPE Program Manager or designee:

  • Supervisory Education Center letter of good standing,
  • Current ACPE Clinical membership, and
  • Ethics section at bottom of this form updated.

In preparation for review for certification as a Supervisory Candidate, documentation ofthe following formal requirements must be submitted for the Appendix 8 to be signed by the ACPE Program Manager or designee:

  • Supervisory Education Center letter of good standing,
  • Current ACPE clinical membership,
  • College graduation and graduate theological degrees (or equivalent),
  • Ordination or commission to function in ministry by an appropriate religious authority, and
  • Faith group endorsement/accountability (or equivalent).

In preparation for review for certification as Associate Supervisor and for Extensions of Supervisory Candidate and Associate Supervisor status, documentation ofthe following formal requirements must be submitted for the Appendix 8 to be signed by the ACPE Program Manager or designee:

  • Supervisory Education Center letter of good standing. No other documentation is required unless there are changes.

In preparation for a Competency Review as an ACPE Supervisor, the only documentation required is submission of this Appendix 8 form, to be signed by the ACPE Program Manager or designee.

Submit this form and required documentation to . Only the signed Appendix 8 must be submitted with materials sent to the Presenter. For each new committee review in the certification process, an updated Appendix 8 must be submitted.

ACPE expects those in the certification process, and thereafter as Supervisors, to report any changes that impact meeting any of these requirements.

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APPENDIX 8 cont’d

Name of applicant and supervisor (if applicable): ______

Letter of Good Standing in current ACPE Sup. Ed. Program from current ACPE Sup. sent to ACPE Yes (____) No (____)

Current paid-up ACPE level of membership: Clinical Member (__) Sup. Cand (__) Assoc Sup (__) ACPE Supervisor (__)

Expiration Date of Supervisory Candidate/Associate Supervisor Status:______

Current faith group ordination/commissioning by: ______

Current faith group endorsement for Sup. Ed by:______

Faith group endorser name and contact information: ______

______

AccountabilityforEthicalConductPolicyReportForm:

(Thisformshouldbesubmittedonlyonce,whenapplyingforclinicalmembership)

Isthereanythingrequiredby theformtoreportsincetheformwassubmitted?YesNo

If yes, please explain:

IftheinformationprovidedonthisAttestationofGoodStandingformisvalidated,theformwill besignedandreturnedtothestudent/supervisorforuseasneeded.Ifnot,theProgram Manager willworkwiththestudent/supervisortocomply.

Iattestthatthisapplicant/supervisorisingoodstandingwithACPE, his/her Supervisory Education Center (if applicable), and his/her faith group:

__

______

ACPE Program Manager or designee SignatureDate