Application for Clinical Pastoral Education

Florida Hospital Division – Center for Pastoral Education

Application for:

CPE Residency:____ Metro-Orlando____ Tampa Region

(Metro Orlando includes: FH Orlando, FH East Orlando, FH Winter Park Memorial, FH Altamonte, FH Apopka, FH for Children, FH Kissimmee, FH Celebration Health,

FH Winter Garden, FH Lake Mary)

Part-Time Programs: _____FH Metro-Orlando

____ Fall (August – December)

____ Spring (January – May)

Part-Time Extended Programs:____ Fall (Oct – April)____ Volusia County

____ Heartland Division

Summer Intensive Programs:_____ Metro Orlando_____ Tampa

(June-August)

Personal Information

(please print legibly)

Name: ______

Date of Birth: ______Place of Birth: ______

Visa Status (if applicable) ______Primary Language: ______

Mailing Address: ______

Telephone:(Home) ______(Cell) ______

Preferred E-mail Address: ______

Faith Group Affiliation/Denomination: ______

Ordained or Commissioned? ___ Yes (Date ______) ____ No

Education

College:______Degree Achieved: ______

Address: ______

Seminary:______Degree Achieved: ______

Address: ______

Additional Graduate Studies: ______Degree Achieved: ______

Previous CPE Experience

DateCenter Supervisor Accredited by

______ACPE ___CPSP ___Other

______ACPE ___CPSP ___Other

______ACPE ___CPSP ___Other

References

Faith Group/Denomination:

Name: ______E-Mail: ______

Telephone number: (work) ______(cell) ______

Address: ______

Academic:

Name: ______E-Mail: ______

Telephone number: (work) ______(cell) ______

Address: ______

Personal:

Name: ______E-Mail: ______

Telephone number: (work) ______(cell) ______

Address: ______

Attach the following written materials with this application upon submission:

  1. A reasonably full account of your life, including important events, relationships with people who have been significant to you, a description of your family of origin as well as your current family relationships. This account should also reflect emotional dynamics that provide an indication of how events and relationships have impacted your learning and personal development. (5 pages maximum)
  2. A description of the development of your spiritual life, including events and relationships that have impacted your faith journey and those that currently inform your belief systems. (3 pages maximum)
  3. A description of the development of your work (vocation) history, including a chronological list of positions held and the dates they were held.
  4. An account of an incident in which you were called upon to help someone in crisis. This account should include:

The nature of the crisis and the request, your assessment of the crisis, what you did/how you responded, a summary evaluation of your response. (If you have had previous CPE, please present this account in the form of a verbatim/case study) (5 page maximum)

  1. Your impression of Clinical Pastoral Education (CPE) and your understanding of how this program will help you meet your educational goals for ongoing or future ministry. (2 page maximum)
  2. If you are an international applicant, you will have to obtain appropriate documentation from U.S. Immigration, which usually implies a visa and a US 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.
  3. Have you ever been convicted or pled nolo to a misdemeanor, a felony, or other crime? Yes___ No___
  4. If you are planning an Admissions Interview at another center other than this one: You will need to schedule and obtain an admissions interview summary prepared by an ACPE, Inc. CPE Supervisor, Associate Supervisor, or another person satisfactory to the center to which you are applying. (There may be a charge for this, by the center or the CPE Supervisor providing the interview). If a written summary is not yet available at the time of this application submission, please provide the following information:

Admission Interview Conducted by: ______

Address: ______

Phone Number: ______Date of Interview: ______

E-Mail Address: ______

  1. Application Fee: $40 non-refundable(application will not be processed or considered until Application Fee is received)

For Applicants with Previous CPE Experience, Please Submit the Following:

  1. Copies of all previous CPE Supervisor Final Evaluations and all Self Final Evaluations
  2. A paper (2-3 pages maximum) describing your most significant learning experiences in CPE and how you have continued to work within the action-reflection-action learning method to reach your ongoing learning goals. Illustrate your awareness of strengths and weaknesses as a professional person.
  3. What are your personal and professional goals and how continued CPE education will aid in your learning process?

I certify that all 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’ve certified with my signature below be false. I hereby give permission to the ACPE, Inc.accredited center 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 verify that if sending in this application electronically it constitutes my electronic signature.

Applicant Signature: ______Date: ______

Instructions for Submission:

Complete and send this application, all supporting materials and the $40 application fee to:

Office of the Registrar

Florida Hospital Division – Center for Pastoral Education

496 W Central Parkway

Altamonte Springs, FL 32714

Or send as a MS Word or .pdf document to:

(electronically submitted materials will not be processed or considered until the $40 application fee is received)

Tuition rate for Level 1 and Level 2 CPE at FH Division- Center for Pastoral Education is:

$300 per unit of CPE

  • A unit of CPE is a minimum of 400 contact hours of classroom and clinical education
  • CPE at FH is a learning community consisting of CPE Supervisors, Assoc. Supervisors, and students in training for Supervisory Certification – your unit may be supervised by someone within any of these positions; in accordance with ACPE, Inc. Accreditation and Certification Standards
  • Note: All Applicants accepted into CPE at Florida Hospital will undergo a Criminal Background Check

**If you are interested in applying for Supervisory CPE at FH Division – Center for Pastoral Education a different application is required. Please contact the CPE Registrar’s office directly at: 407-303-5297 or via email to: o have that application forwarded to you.

CPE at FH Division – Center for Pastoral Education is accredited for Level 1, Level 2 and Supervisory CPE by: ACPE, Inc.,

One West Court Square, Suite 325, Decatur, GA 30030 - 404-320-1472

CPE Application, Level 1 and Level 21 of 3