Queensland Institute

of

Clinical Pastoral Education Inc.

CONFIDENTIAL

Application for enrolment

A. CPE Unit: (to which this application relates)

Centre: (Institution) ______

______

Address: ______

______

______Postcode: ______

Level: Foundational[ ] Advanced[ ] Mode: Part-time [ ] Full-time [ ]

Commencement Date: ______

Supervisor(s): ______

B. Applicant’s personal details:

Surname: ______Title: ______Sex: ______

Given Names: ______Phone: w ______

Address: ______h ______

______m ______

______P’code: ______Email: ______

Date of Birth: d ___ m ___ y ______Place of Birth: ______

Marital Status: ______Spouse: ______

Children: (Names & Ages) ______

______

C. Church Affiliation:

Denomination: ______

Local Church/Parish: ______

Address: ______

Name of Parish Priest/Minister: ______

Address: ______

______Phone: ______

D. Accreditation for Ministry: (ordination/professional/commissioning/etc)

Name of religious body: ______

Location: ______

Date: ______

E. Tertiary Education:

Course: Institution: Length: Date of Awards:

______

______

______

F. Theological Education: (if not cited above)

Course: Institution: Length: Date of Awards:

______

______

______

G. Other Training:

Course: Institution: Length: Date of Awards:

______

______

______

H. CPE units already undertaken:

Centre: Location: Completion Date: Supervisor:

______

______

______

I. Details of any other CPE applications previously declined or currently being processed:

______

______

______

______

______

______

J. Past Experience of Ministry:

Description: Location: Dates: Hours/week:

______

______

______

______

K. Present Ministry/Pastoral Work:

Description: Location: Dates: Hours/week:

______

______

______

______

L. Present Pastoral Responsibilities/Roles: (give details)

______

______

______

______

______

______

M. Reasons for lodging this application: (your expectations and goals)

______

______

______

______

______

______

N. Other Information: (considered relevant to this application)

______

______

______

______

______

O. Referees: (three required, one from present or recent employment)

Name: Address: Phone:

______

______

______

______

P. Documents to accompany application form:

  1. Supervisor’s final evaluation report of last CPE unit undertaken (if applicable).
  2. An autobiographical statement giving an account of your life, including emotional, social and spiritual development, relationships with significant others and important events and experiences. (1,000 words minimum)
  3. A description and evaluation of a recent helping incident in which you were personally involved. (500 words approximately)
  4. A statement of your learning goals and expectations for this unit. (250 words approximately)
  5. A statement from your employer endorsing your application (if applicable).
  6. A recent photograph.
  7. A processing fee of $30 (non-refundable, payable to QICPE Inc).

Direct Debit or at Westpac bank: QICPE Inc, BSB: 034 072 A/C: 186 321

Cheque: Posted to PO Box 37, Everton Park Qld 4053

Credit Card: $31.50 and paid via

Q. Lodging completed Application Form:

Mail to the Supervisor of the unit for which you are applying.

See for details.

R. Permission for restricted access to my contact details.

As part of my applicaton, I give my permission for my name,mobile number and email address to be accessed by the QICPE Secretary and Treasurer for the purposes of facilitating official QICPE processes (eg invoicing, membership matters, invitations to QICPE functions etc).

S. Signature

______

Date Signature of applicant