2.20 Application for Maintenance of Educational Standing (Moes)

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2.20 Application for Maintenance of Educational Standing (MoES) ©

This form is divided into three sections: data, rationale and signatures. All three parts of the Form are to be completed by all applicants for Maintenance of Educational Standing. In responding to Part 2, limit your rationale to address only the level of educational standing at which you need to remain and for which you are seeking Maintenance of Educational Standing at this time.

You are asked to:

1) Complete the Application, including all signatures other than the Certification Chairperson. [Note: While there is no need to provide lengthy detail or personal disclosure, if you want to use additional pages please do.]

2) Assemble copies of all Formal Documents requested.

3) Mail the completed Application, Formal Documents, and designated Maintenance of Educational Standing fee (posted on the CASC website) to the Certification Committee Chairperson (details at end of form).

Personal Information: (please type or print)
Legal Name:
Address:
Phone #: / Home: Office:
Email:
CASC Region:
Maintenance of Educational Standing Request:
Provisional Supervisor-Educator: / CPE PCE
Completion of your formal review with Regional Admitting Committee for the Provisional standing in which you are seeking Maintenance of Educational Standing:
Year: / Region:
Is your information in the CASC directory correct? / Yes / No
If “No”, indicate what changes need to be made:
Formal Documents that are to accompany this application:
A copy of the current year’s CASC membership receipt
A copy of the CASC/ACSS receipt for applicable Maintenance of Educational Standing fee ($150)
Evidence of participation in the organization life of CASC (see Chapter 2, Section VII).
A brief description of your participation in the life of your chosen Faith Community (Chapter 2, Section VI).

***Note – electronic scans of documents are preferred.

Rationale for Remaining at this Level of Educational Standing

Briefly summarize your reason(s) for needing to remain at this level of educational standing for the next 3 years?

Briefly share any other relevant information that you believe to be important for this application and wish to have included as a part of this document:

Accountability:

If employed, is your employer aware that you are remaining in a level of educational standing that normally proceeds toward professional certification? Yes No

Signatures

My signature certifies that I am not currently the subject of an ethics investigation or in an appeals process for any alleged violation of the CASC Code of Ethics and Professional Conduct, and I do not anticipate such an investigation to be initiated during the process of my application.

Applicant Signature:
Certification Chair Signature:
Date Application Received:

Once this form has been completed and signed by the applicant and Certification Committee Chairperson, the original is sent to the applicant and a copy of the original is held on file with the Certification Committee. While in Maintenance of Educational Standing, the timelines will be monitored by the Certification Committee and candidates will be notified regarding renewal (if any), deadline dates, and designated fee.

This document becomes a part of the applicant’s Formal Documents and must be submitted as specified in the Standards.

Submit this form electronically to the Certification Chair

Ajith Varghese

Manager, Spiritual & Religious Care

The Scarborough Hospital
3050 Lawrence Ave. East
Scarborough, ON M1P 2V5

Phone: 416 438 2911 Ext: 6425

Email:

Revised October 2017 Posted December 2017, 2.20 Page 1 of 2