Chaplaincy Services

Clinical Pastoral Education at Memorial Hermann Hospital System

You may print this form out and mail it to the Clinical Pastoral Education Office to which you are applying.

Name______________________________________________

Application for:

____ First Year ___ Second Year ___ Summer
___ Community (part-time) ___ Supervisory

Present Mailing Address:

___________________________________________________

Telephone Home (____)____________
Office (____)__________

Permanent Mailing Address:

___________________________________________________

Telephone Home (____)____________ Office (____)__________

Denomination/Faith Group Affiliation:
____________________________________________

Association, Conference, Diocese, Presbytery, Synod:

____________________________________________

Present Position ______________________________________

Ordained? _______ Date______________

EDUCATION: Degree

College_____________________________________________

Seminary____________________________________________

Graduate Study_______________________________________

Previous Clinical Pastoral Education:

Dates Center Supervisor

_________________
___________________________________________________

References and Addresses:

Denomination/Faith Group:
___________________________________________________

Address_____________________________________________

Zip Code _____ Tele.#______________

Academic
___________________________________________________

Address_____________________________________________

Zip Code _____ Tele.#_______________

Other:
___________________________________________________

Address____________________________________________

Zip Code _____ Tele.#________

Attach to Application:

A reasonably full account of your life, including important events, relationships with people who have been significant to you, and the impact these events and relationships have had on your development. Describe your family of origin, your current family relationships and your educational growth dynamics.
A description of the development of your religious life, including events and relationships that affected your faith and currently inform your belief systems.
A description of the development of your work (vacation) history, including a chronological list of positions and dates.
An account of an incident in which you were called to help someone, including the nature of the request, your assessment of the "problem," what you did, and a summary evaluation. If you have had previous CPE, include this information in verbatim form.
Your impression of Clinical Pastoral Education and your educational goals, including how this training will be used to meet your goals for doing ministry.
An admissions interview by an ACPE Supervisor or another qualified person. (CPE Supervisors, Seminary Liaison Professors, and Regional Directors may recommend interviewer).

Admission Interview Conducted by _________________________

Address ___________________________________________

Zip code________

Application fee required by center --- $30.00 (Fee waived for summer applicants only)

THOSE WITH PREVIOUS CPE SHOULD COMPLETE THE FOLLOWING:

Copies of previous CPE evaluations written by you and your supervisor.
What was the most significant learning experience in previous CPE and how have you continued to work in this learning method? Illustrate your strengths and weaknesses as a professional person.
What are your personal and professional goals and how will continued training aid that process?

Signature of Applicant_________________________________

Date____________ Social Security # ________________

Send this application directly to the CENTER to which you are applying.