Read instructions and review this online form carefully before completion. Several responses include the attachment of electronic documents, such as resumes. Please prepare or accumulate these documents prior to beginning the completion of this form.

All questions must be completed. International applicants have additional requirements and deadlines.

Fields marked with * are mandatory. Please enter N/A if appropriate.

All Information Must Be Completed

Which program is this application for? * Summer Extended Residency (only at York) Certified Educator CPE

Location Preference for Summer/Extended * WellSpan York Hospital WellSpan Gettysburg Hospital

Name *

Mailing Address *

City *

State *

Zip Code *

Country *

Telephone *

Email *

Permanent Address *

City *

State *

Zip Code *

Country *

Telephone *

Denomination/Faith Group Affiliation *

Jurisdiction/District/ Diocese/Conference/Association *

Ordained/Licensed/Appointed

Present Position *

College: Degree/Date *

Seminary: Degree/Date *

Grad School/Other: Degree/Date *

Previous Clinical Pastoral Education

Date

Center

Certified Educator

Date

Center

Certified Educator

Date

Center

Certified Educator

Attachments

An account of your life
Include significant persons and events (e.g. marriages, divorces, children, deaths, etc.) as they have impacted your growth and development. Describe your family of origin, current family relationships, and significant social relationships and their impact on your ministry. (20Mb File Size Limit) Two pages

Accepted file types: .pdf, .jpg, .png

*

A description of your spiritual growth and development
Describe your faith development/history and include personal conversions, call to ministry, and significant persons and events that have impacted your spiritual growth and development. Indicate your current relationship with faith group-faith group authority person and present standing with your faith group. (20Mb File Size Limit) Two pages

Accepted file types: .pdf, .jpg, .png

*

A description of your work (vocational) history
Include a chronological list of jobs/positions dates of employment and a brief statement of your current employment and work relationships. A resume is sufficient. (20Mb File Size Limit) Two pages

Accepted file types: .pdf, .jpg, .png

*

Applicants with previous CPE should attach copies of all previous self and supervisor evaluations.

Accepted file types: .pdf, .jpg, .png

*

A recent account of a 'helping incident' in which you were in a pastoral/spiritual role with the person/family that you were providing “help”/ministry.
(20Mb File Size Limit) Four pages a. Include the nature of the request, your assessment of the issue and a brief evaluative summary of what you did and how you helped. b. If you had prior CPE, please use verbatim format and indicate the most significant learning in your previous training.

Accepted file types: .pdf, .jpg, .png

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Your impressions of Clinical Pastoral Education
(20Mb File Size Limit) One page a. Indicate what you believe CPE to be. b. Indicate if CPE is being required of you. c. List personal/professional strengths/weaknesses. List two learning goals for this program and how CPE training will help you address them. One page a. Please list personal/professional strengths/weaknesses. b. Indicate any personal/professional learing goals and how this training will address your learning and/or vocational goals.

Accepted file types: .pdf, .jpg, .png

*

You are required to complete an admission interview with an ACPE Supervisor or a person approved by the Center for which you are applying. Contact the local CPE center if you need help in locating an interviewer in your area. For residency, an on-site interview is a requirement.

WellSpan’s requirement is a submitted application by September 1 of the year prior to entry. You will have to obtain appropriate documentation from U.S. Immigration, which requires a visa and a US Social Security number. This documentation should be approved at least 6(six) months prior to the program. See http://www.acpe.edu/StudentsIntlStudents.html (ACPE website)

If offered employment, can you submit verification of your legal right to work in the U.S.? Yes No

I hereby give my consent to the ACPE center to which I am applying to access my CPE evaluations and supervisory personnel about matters pertaining to this application.