The Institute for Clinical Pastoral Training

ApplicationforClinical Pastoral Education Instructions

Date:

Instructions

ApplicantsforClinical Pastoral Education

ApplicantsforCPEcompleteallsectionsoftheapplication.

Complete the entire application.
Submitthecompleteapplicationpacket(electronicallyispreferred)toICPT(), send via USPS to the address below, or faxi it to (407) 218-6481.
Usingthelinkoneithertheapplicationwebpage,submittheappropriatefee—application;$50.00;tuition;$600.00.
To apply for a tuition payment plan, submit the “Tuition Assistance Request found on the ICPT website application page.

Mailing address:

The Institute for Clinical Pastoral Training

PO Box 620822

Orlando FL 32862-0822

Application Clinical Pastoral Education (CPE)

I am applying for Long-distance training On-site trainingUnit Date:

Site Location:

Unit Type: Standard Extended Supervisor-in-Training

Section I – Personal Information

First Name (given): / Middle Initial/Name: / Last Name (surname): / Suffix (Jr., Sr., etc):
Street Address:
Street Address 2:
City: / State: / Zip/Postal Code: / Primary Phone Number:
E-Mail: / DOD E-Mail (military only):
Religious Affiliation: / Ordained/Consecrated/Licensed?
Yes No / Date:

Section 2 – CPE Units to be Recognized

Date Completed: / Unit Type:
Basic/Level IAdvanced/Level II / Affiliation:
Basic/Level IAdvanced/Level II
Basic/Level IAdvanced/Level II
Basic/Level IAdvanced/Level II
Basic/Level IAdvanced/Level II

Attach additional pages if necessary. Only units from ACPE or CPSP qualify for automatic recognition. All others are on an exception basis.

Clinical Pastoral Education ApplicationPage 1

Section 3 – Certifications to be Reciprocated

Affiliation (BCI, CPSP, Etc.): / Certification Earned: / Date Earned:

Attach additional pages if necessary. Only certifications from BCI and CPSP are recognized for reciprocation. All others are on an exception basis.

Section 4 – Employment

Current Employer/City, State: / Position: / Dates:
Previous Employer/City, State: / Position: / Dates:

Section 5 – Scholastic

Highest Degree Obtained:
H.S Diploma / Associate / Bachelors / Masters / Doctorate
Undergraduate
School: / City/State: / Degree Awarded/Subject: / Dates Attended:
Graduate

Section 6 – Narratives (for all but narrative 1 submit additional sheets)

Where/How did you find out about ICPT CPE?

Please provide a reflective autobiography giving special attention to pivotal life events and relationships that have shaped you as a person.
Please describe a situation when you helped another who was facing a difficult life situation. Supply a reflective critique of your intervention. Applicants with previous CPE experience will provide a case study (verbatim) to answer this.
What is your understanding of Clinical Pastoral Education and, what do you hope to gain in both personal and professional development?
Please provide a brief Curriculum Vitathat describes your education, training, and work experience.

By my signature below (either electronically or in writing), I affirm that all information contained herein is truthful and current. I understand that falsifying my application will result in disciplinary action.

Date: Printed Name:

Signature:Electronic Signature (initials):

Section 7 – Refund Policy

Clinical Pastoral Education Tuition Refund Policy

Name: Date:

The Institute for Clinical Pastoral Training (ICPT) has developed this refund policy to clearly identify the refund due in the event that the student cancels, withdraws, or is terminated from the program or if ICPT cancels a particular class.

Definitions

ICPT Cancellation—ICPT cancels a class prior to the projected start date.
Student cancellation—the student does not begin class or submit any class required documentation.
Student withdrawal
On-site unit—the student will be considered withdrawn if the student does not attend two (2) consecutive classes or does not submit two (2) consecutive assignments sessions without contacting their supervisor.
On-line unit—the student will be considered withdrawn if the student does not submit two (2) consecutive required assignments, misses two (2) consecutive supervisory sessions, or is without contact for more than two (2) consecutive weeks.
Student Termination—ICPT terminates the student for cause.
Last Day of Attendance (LDA)—the last day the student has submitted a required assignment, participated in a supervisory session, or participated in a forum board.
Date of Determination (DOD)—the date the Tuition Refund Worksheet is prepared.

Refunds

Rejection of Applicant: If an applicant is rejected for enrollment by an institution a full refund of all monies will be paid to the applicant, less a maximum application fee of $50.00.
Program Cancellation: If ICPT cancels a program subsequent to the student’s enrollment, all monies paid will be refunded to the student.
Cancellation prior to the start of class or No Show: If an applicant accepted by the institution cancels prior to the start of scheduled classes or never attends class (no-show), all monies paid will be refunded, less an application fee of $50.00.

Withdrawal or Termination after the Start of a Unit

Refund amounts will be based on the students last date of attendance (LDA). A day of attendance is either:
On-site unit—the day a student either submitted a required class document, or participated in a peer group session, or participated in a supervisory session; whichever is later.
On-line unit—the day a student last posted in the group forum, submitted a required class document, or participated in a supervisory session; whichever is later.
First week of the unit (start date + 7 days)—The student will be refunded 90% of the tuition paid as calculated on the Tuition Refund Worksheet.
From the beginning of the second week (day 8) through the end of the sixth week (day 42)—The refund will be calculated using a pro rata portion of the tuition due for the unit plus 10% of the unearned tuition for an administrative fee. The calculation will be via the Tuiton Refund Worksheet.
After the sixth week (day 43 forward)—there is no refund. The full tuition is retained by ICPT and the student is responsible for any unpaid portion.
Refunds will be processed, via check, no later than 45 days from the DOD and sent to the address on file for the student.

Tuition Refund Worksheet

A copy is attached to this document.

Signature

I have read and I understand the ICPT refund policy. I agree to abide by this policy.

Signature: Date:

Electronic Signature (initials):