Application Clinical Pastoral Education (CPE) - Residency

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					 Application: Clinical Pastoral Education (CPE) – Full Time
                      CASC Supervisors of the Central Ontario Region
                                    www.cpe-pce.ca
Important: Before using this form, you must save it to your local hard drive first. Please save
the form again once it is completed and attach it to the e-mail submitting your application.
Course Information
Please note here the Teaching Centre to which you are applying as well as the information for
the specific unit you wish to apply. You may also note alternate choices here in the event that
space is unavailable where you are applying. Your application may be forwarded to another
teaching centre if your first choice is not available.


Personal Information
   First Name & Initial:
           Last Name:
             Birth date: dd-mm-yyyy
       Street Address:
            City/Town:
          Postal Code:
              Country:
  Daytime Telephone:                   (with applicable area/country code)
       Email Address:


Faith Information
           Faith group/religion:
Faith Association, Conference,
Diocese, Presbytery, or Synod:


Past Education
In this section, outline your post-secondary education, including your university degree, your
theological degree (if applicable), and other relevant degrees.
            College/University:
             Degree Received:
              Graduation Year:
           Theological School:
             Degree Received:
                  CPE Application Form – CASC Supervisors of the Ontario Central Region
                                                 -2-


                Graduation Year:
    Other/Additional Education:
                Degree Received:
                Graduation Year:


Current Student Status
All students enrolled in a CPE unit offered by a Toronto CASC (formerly CAPPE) supervisor
must register through a TST member college. Fees will be paid by the student to the member
college through the registration system, ROSI. Students who are not already enrolled within a
TST College must apply both to the supervisor offering CPE and to a TST college as a special,
non-degree student. Students will be subject to the same admission procedure and criteria as
other non-degree students as per college policy, and should expect to submit all postsecondary
transcripts and adhere to the application deadlines of the College.


  In which (TST or other) College/Institution
                are you currently enrolled?


Type of CPE Unit (Check One)
   Basic Unit
   Advanced Unit (Prerequisite: 2 previously completed Basic CPE Units)
First Choice
                         Teaching Centre:
                               Beginning: dd-mm-yyyy
                                 Ending: dd-mm-yyyy
         If the centre to which you are
applying has multiple locations, which
location which you prefer to study at?
Note: It may not be possible to place you in a specific location in multi-location centres.
Second Choice
                         Teaching Centre:
                               Beginning: dd-mm-yyyy
                                 Ending: dd-mm-yyyy
         If the centre to which you are
applying has multiple locations, which
location which you prefer to study at?
Note: It may not be possible to place you in a specific location in multi-location centres.




Revised September 2010
                  CPE Application Form – CASC Supervisors of the Ontario Central Region
                                                 -3-


Third Choice
                         Teaching Centre:
                               Beginning: dd-mm-yyyy
                                 Ending: dd-mm-yyyy
         If the centre to which you are
applying has multiple locations, which
location which you prefer to study at?
Note: It may not be possible to place you in a specific location in multi-location centres.


Past CPE Units Taken
List past Clinical Pastoral Education (CPE) or Pastoral Counselling Education (PCE) units
completed (I suggest we also ask for completed PCE units, especially as some students wish to
move into advanced after taking one CPE and one PCE.)
CPE/PCE Unit #1
      Institution/Centre:
             Supervisor:
       Year Completed:
CPE/PCE Unit #2
      Institution/Centre:
             Supervisor:
       Year Completed:
CPE/PCE Unit #3
      Institution/Centre:
             Supervisor:
       Year Completed:
CPE/PCE Unit #4
      Institution/Centre:
             Supervisor:
       Year Completed:


Past CPE Interviews
Outline past CPE or PCE courses which you did not complete, please provide a brief reason for
why you did not complete the course.
CPE/PCE Interview #1
      Institution/Centre:



Revised September 2010
                  CPE Application Form – CASC Supervisors of the Ontario Central Region
                                                 -4-


             Supervisor:
      Date of Interview:
CPE/PCE Interview #2
      Institution/Centre:
             Supervisor:
      Date of Interview:
CPE/PCE Interview #3
      Institution/Centre:
             Supervisor:
      Date of Interview:


References
Please enter the names and contact information of two references, including one from a
theological college (if appropriate) and one from your denomination or faith group. The persons
listed should be people who know you as a person and a spiritual or religious care giver who
can comment knowledgeably on your character, your nature, and professional functioning —
including your capacity to learn. In the position field, please note their work, for example
―Professor of Theology‖ Or ―Minister at ....‖.
Reference #1
                   Name:
        Street Address:
              City/Town:
           Postal Code:
                 Country:
   Daytime Telephone:                      (include area/country code)
         Email Address:
                 Position
Reference #2
                   Name:
        Street Address:
              City/Town:
           Postal Code:
                 Country:
   Daytime Telephone:                      (include area/country code)
         Email Address:



Revised September 2010
                    CPE Application Form – CASC Supervisors of the Ontario Central Region
                                                   -5-


                   Position


1.          Autobiography: (SECTION 1: Basic Supervised Education, Subsection 2: Goals of
            Basic SPE 201.0)
Our personal, family, educational, and vocational history informs our understanding of our
personal and professional identity. Include a three part essay addressing the following items


            i)     A reasonably full account of your life. Include, for example, significant and
                   important persons and events, especially as they have impacted, or continue to
                   impact, your personal growth and development.

            ii)    Describe your family of origin, current family relationships, and important and
                   supportive social relationships.

            iii)   Describe how CPE has informed your understanding of your personal and
                   professional identity. Include examples drawing on your personal, family,
                   educational, and vocational history.

2.          Learnings from your CPE experience


            a.     Drawing upon your prior CPE, please indicate the most significant learning
                   experience you had. State how you have continued to use the clinical method
                   since this experience.
            b.     Indicate strengths and weaknesses that you have as they relate to your spiritual
                   care giving and your identity as a professional person.
            c.     Indicate any personal and/or professional learning goals and issues that you
                   have at this time and how you believe that CPE will help you to attain or address
                   these learning goals and issues

3.          Spiritual Care Identity and Areas of Continued Integration


      i.           What is your definition of spiritual care giving in an institutional context and what
                   are the areas of struggle for you presently, both theologically/spiritually.

      ii.          Include how your story/narrative (personal, family, educational, and vocational
                   history) is expressed in your spiritual care giving.

     iii.          Include areas (personal, family, spiritually, theologically) that you know continue
                   to play at part in your spiritual care giving, and you want to explore.

4.    Include a copy of all self evaluations and all supervisors’ evaluations of any CPE
or PCE unit that you have taken in the past.




Revised September 2010
                    CPE Application Form – CASC Supervisors of the Ontario Central Region
                                                   -6-


Submit your Application
I certify that, to the best of my knowledge, all the information in this application is correct. If I am
applying for an advanced-level CPE unit, I certify that I have previously completed at least two
basic units of CPE.
                    Name:
        Date Submitted: dd-mm-yyyy
Contact Addresses
Please submit this application to the appropriate teaching centre. Make sure to save this
application to your local hard drive first, then attach it to your application e-mail message.
Please replace the ―[at]‖ with the ―@‖ symbol in the e-mail address you use.
Centre Name                                            E-mail
Bridgepoint Health                                     apply.bridgepointhealth[at]cpe-pce.ca
Scarborough Hospital – General Campus                  apply.scarboroughgeneral[at]cpe-pce.ca
St. Michael’s Hospital                                 apply.stmichaels[at]cpe-pce.ca
Sunnybrook Health Sciences Centre                      apply.sunnybrook[at]cpe-pce.ca
University Health Network                              apply.uhn[at]cpe-pce.ca


More information on each teaching centre, including telephone numbers, may be found at:
                                         www.cpe-pce.ca/centres.asp
Information on CPE supervisors is available at:
                                         www.cpe-pce.ca/contact.asp
Privacy Policy
The CASC (formally CAPPE) Supervisors of the Ontario Central Region (CSORC) are committed to maintaining
your trust and confidence. The following privacy policy is designed to protect personal information you provide on
our website. Your right to privacy is very important to us.
The purpose of our website is to educate and inform our students, potential students, applicants, and the general
public about the programs offered by CSORC. When you visit this site and access information, you are anonymous.
We do not require you to provide personal information to view it.
However, when you apply for one of CSORC's programs, we ask for quite detailed information from our applicants.
Given the sensitive nature of both Clinical Pastoral Education (CPE) and Pastoral Counselling Education (PCE)
programs - both of which involve counselling clients - CSORC has a responsibility to protect the student's potential
clients by thoroughly reviewing the qualifications, experience, and gifts of each person applying to one of our
programs
This being understood, we will also endeavour to protect the confidentially of the information which applicants
provide us. We will therefore not share this information with anyone who is not involved in the application approval
process.
We will not use the applicant's e-mail or contact information for purposes other than contacting the applicant
regarding their application status or, subsequent to registration, to contact students regarding matters directly related
to their participation in CSORC programs.




Revised September 2010