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Clinical Pastoral Education Application Form

1. Three "stories" (one-half to one page each) of important events/people/memories in your life. These may be
anything of significance, but pay special attention to those which triggered life-change for you.
2. A religious autobiography (two to three pages). Include information about faith group / denominational
activities of each parent prior to your birth, as well as an account of your own religious pilgrimmage. If you
have held leadership positions of any kind in your religious group, describe each one.
3. An account of a time when you helped someone else (one-half to one page). Be specific about the need as
you understood it, and about how your provided help.
4. A statement about why you want Clinical Pastoral Education. If you have specific ideas about what you
would like to learn, include them.
5. If you have had previous Clinical Pastoral Education, please include copies of evaluations written by
you and by your supervisor(s).


* Indicates required information
Unit Desired 
Applicant Information 
Name: 
Address: 
City 
State 
Zip 
Telephone number 
Home telephone number 
Work telephone number 
Cellphone number 
E-mail address(es) 
Social Security Number: 
Denomination/Faith Group Information 
Education 
Name of Religious Body: 
Ordained? * 

Date of Ordination:    (mm/dd/yyyy)
Conference, Presbytery, Diocese, Association, Synod, etc: 
College & Degree 
Seminary & Degree 
Graduate Study & Degree 
Clinical Pastoral Education 
Name of Center; Dates Attended; Supervisor's Name 
References 
Denomination/Faith Group References 
Academic References 
Other References 
Stories: Please write three (3) stories about important events/people/memories in your life. These may be anything of significance, but pay special attention to those stories that triggered life-change for you. 
Attachments 
Story #1 
Story #2 
Story #3 
A religious autobiography.  
Please include information about your parents faith group activities before your birth, and an account of your own religious pilgrimmage. Describe one leadership position you have held in your religious group if applicable. 
Please give an account of a time when you helped someone else. Be specific about the need as your understood it, and how you provided help. 
Please explain why you want Clinical Pastoral Education. If you have specific ideas about what you would like to learn, include them. 
If you have had previous Clinical Pastoral Education, please include copies of evaluations written by your supervisor(s). 
Authentication * 

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