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ASSOCIATION OF CLINICAL PASTORAL EDUCATION (IRELAND) LTD.

COURSE APPLICATION FORM

CPE Programme:

Section (i)

Section (ii)

Preferred Centre:

Section (iii)

First Name: / Surname: / Title:
Name as registered on Birth Certificate: / Date of birth: / Nationality:
Correspondence Address: / Home Tel. No:
Work Tel. No.:
Fax No.:
Email:

Section (iv) SECOND LEVEL EDUCATION

Exam(s) Taken

/

Year

Section (v)FURTHER EDUCATION

Academic, Professional, Other Qualifications (Third-Level)

  1. Full-time Courses Completed

Name of College / Dates From/To / Course(s) Taken / Cert. Diploma, Degree etc. / Name of Conferring Body
  1. Part-time Evening/Short Courses

Name of College / Dates From/To / Course(s) Taken / Cert. Diploma, Degree etc. / Name of Conferring Body

3.Current Courses Being Undertaken

Section (vi)EMPLOYMENT HISTORY

List earliest employment and work forward to current employment.

Dates From/To / Name/Address of Employer &/or Section/Dept. Employed / Title of Post
and
Brief Statement of Duties and Responsibilities

PROFESSIONAL REGISTRATION

If registered in any Professional Register, please give

(a) Registration No.:

(b) Title of Register:

(c) Date of First Registration:

Section (vii) ADDITIONAL INFORMATION

Please give particular details of your professional or voluntary Pastoral Experience.

Note: If insufficient space is provided, please continue on separate sheets of paper.

Section (viii) CONFIDENTIAL TO ASSESSMENT PANEL

Give a reasonably full account of your life including:

(a)A description of your immediate family, important events and what you consider was the impact of these on your development (at least 500 words).

Note: If insufficient space is provided, please continue on a separate sheet of paper.

(b)An account of your spiritual/religious development and your reason for applying

for this programme.

(c)Describe briefly your present physical and emotional health. Mention any health problems.

Note: If insufficient space is provided, please continue on separate sheets of paper.

Section (ix)a description of an incident in which you were called to help someone, the nature of the requestand how you attemptedto help (at least 500 words).

Note: If insufficient space is provided, please continue on separate sheets of paper.

Section (x) PLEASE LIST TWO REFEREES

One must be your current/most recent employer/supervisor.

One must be your Bishop/Religious Leader or Pastor.

Name:
Position:
Address:
Tel No:
Name:
Position:
Address:
Tel No:
DECLARATION

PLEASE RETURN COMPLETED APPLICATION FORM TO:

PLEASE RETURN COMPLETED APPLICATION FORM TO:

The Director of Chosen Centre

FORM A

ASSOCIATION OF CLINICAL PASTORAL EDUCATION (IRELAND) LIMITED

I ______(Name of Referee) hereby state that

______(Name and title of Applicant) is a

Person of good character and reputation in the ______

(Name of Diocese/Congregation/Presbytery/Conference/Association/Order).

There is nothing, to my present knowledge, in his/her background that might suggest that he/she would be unsuitable for working with minors, nor has he/she any continuing alcohol or substance abuse problem.

S E A L

Signature______

(Referee)

Print/type postal address:______

______

Date:______

AGREEMENT OF APPLICANT

I ______ (Print/type name of Applicant) hereby

Confirm the information that I have given to my Referee is correct.

I agree to comply with local hospital regulations.

Signature:______

Date:______

NOTES ON COMPLETION OF THE APPLICATION FORM

  1. (i) You must include TWO photocopies of your Application Form with the original.

(ii) Write clearly in black ink (not black marker) and BLOCK CAPITALS OR

TYPE.

  1. The Clinical Pastoral Education Programme (CPE) offers preparation for ministry leading to possible certification as a Healthcare Chaplain on meeting the requirements of Healthcare Chaplaincy Board.
  1. In regard to Section (v) 1. – If you have previously participated in a CPE programme(s) please state Centre (under College) and supervisor’s name (under Conferring Body).

Enclose a copy of all evaluations (your own and supervisors) with this form.

  1. In regard to Section (vii), please note that evidence of relevant Pastoral Experience is a minimum requirement.
  1. In regard to Section (x), references should be sent directly to the Director of the Centre by the referee. Applicants will not be called for interview until the references have been received. It is the responsibility of the applicant to ensure that the references are forwarded to the Director of the Centre. Form A is not a reference.

LIST OF CENTRES:

CPE SupervisorDirector

CPE ProgrammeCPE Programme

St. Vincent’s HospitalSt. John of God Hospital

Elm ParkStillorgan

DUBLIN 4Co. Dublin

One course only: Sept/December

Director

CPE ProgrammeDirector

Mater Misericordiae HospitalCPE Programme

Rosary HouseSt. Luke’s Home

Eccles Street Mahon

DUBLIN 7 Cork

Extended Unit:October/February

Director

CPE Programme

Cork University Hospital

Wilton

CORK

One course only: April /July