CLINICAL PASTORAL EDUCATION (C.P.E.)

Hunter Region

MIXED EXTENDED UNIT

Application Form

(Please complete both sides)

Level applied for:Basic/Advanced (Cross out whichever does not apply)

PERSONAL DETAILS (Please print)

Name:……… ………………………………………….…………………………………….………………………………………………………………….

TitleFirst NameMiddle Name(s)Family or Last Name

Address:………………………………………………………………………………………………………………………………………………………………………………………

City/Suburb:…………………………………………………………………………………..….Post Code: ……………………………………………………..

Phone:…………………………………………………………………………….Email: …………………………………………………………………………….

Date of Birth:…………… / ………….. / …………….Denomination:………………….…………………………………………………….….

Spouse:………………………………………………………………………………………………………………………………………………………………..………………….

Children:……………………………………………………………………………………………………………………………..………………………………………………………

Names and ages:……………………………………………………………………………………………………………………………………………….

TERTIARY EDUCATION COURSES (Include current courses)

Course / Institution / Length / Date of Award

THEOLOGICAL EDUCATION (Include current course)

Course / Institution / Length / Date of Award

OTHER TRAINING (Include current courses)

Course / Supervisor/Trainer / Length / Date of Completion

PASTORAL EXPERIENCE

Location / Date Commenced / Date Completed / Hours per week

REFEREES:Please provide the names of three people who are prepared to act as referees for you.

Name / Address / Phone Number

Are you a recognised candidate for the ordained ministry of your Church? (Cross out whichever does not apply Yes / No

Are you doing this course as part of a diploma/degree from an accrediting institution/body? Yes / No

If yes, please state the name of the institution ……………………………………………………………………………………………………………..

Prerequisite: At least one Basic unit of CPE. For Advanced Level: At least two Basic Units of CPE and evidence of competence in relation to the Basic Unit objectives.

Please include the following with your application:

Mixed Extended Unit (Basic Level)

  1. An updated autobiographical statement (1,000 words).
  2. A statement of your reasons for doing the course.
  3. A statement of what you hope to gain from the course.
  4. A $10.00 processing fee (non-refundable).

Advanced Level(additional to the above)

  1. A copy of your final evaluation of your last CPE Unit.
  2. A copy of your supervisor’s evaluation of that Unit.

Please note that your application will not be considered without the specified documentation.

SIGNED: ……………………………………………………………………………………..DATE:…………………………………………………..

Please return the completed form with attachments and processing fee to:

Please make cheques payable to: The Hunter Centre for Clinical Pastoral Education

BSB: 650 400 Account: 970282504 (Newcastle Permanent)

Please post to:The Rev’d Dr Barbara Howard

Chaplains’ Department

JohnHunterHospital

Locked Bag No 1

HUNTER REGION MAIL CENTRE 2310

All inquiries to the above or phone: 49753672 or 0414 551 751.