CPE Application Fill in the various fields of the first part of this application on your computer, and then print it and mail with your narrative responses to the items in the second part of the application. If you wish to submit materials electronically, you may negotiate that process by contacting the Department of Pastoral Care at 215-662-2591 or at ralph.ciampa@uphs.upenn.edu. Additional information is available on our Application Procedures page. Name: Application for: Please choose one Winter Spring Summer Fall Extended Year Earliest Date You Can Begin: Current Standing in CPE: Please choose one Basic Advanced Supervisory Prospective CPE Student E-mail Address (optional): Present Mailing Address Permanent Address Street City State Zip Code Phone Street City State Zip Code Phone Denomination/Faith Group Affiliation: Association, Conference, Diocese, Presbytery, Synod: Present Position: Ordained? Yes     No       If yes, date: Education Degree College Seminary Graduate Study Previous Clinical Pastoral Education Dates Center Supervisor References and Addresses: Denomination/Faith Group Academic Other   Please check the following two questions: If you are an international applicant, you will have to obtain appropriate documentation from US Immigration, which usually implies a visa and a US Social Security number. Therefore, international students should have such documentation approved at least six (6) months prior to the start of the program to which they are applying. If offered employment, can you submit verification of your legal verification of your legal right to work in the US? YES NO Have you been convicted or pled nolo to a misdemeanor (other than traffic violations) or felony? YES NO Attach the following to your application: (Please limit your answers to a reasonable length, not to exceed five pages.) A reasonably full account of your life, including important events, relationships with people who have been significant to you, and the impact these events and relationships have had on your development. Describe your family of origin, your current family relationships and your educational growth dynamics. A description of the development of your religious life, including events and relationships that affected your faith and currently inform your belief systems. A description of the development of your work (vocation) history, including a chronological list of positions and dates. An account of an incident in which you were called on to help someone, including the nature of the request, your assessment of the "problem," what you did, and a summary evaluation. If you have had previous CPE, include this information in verbatim form. Your impression of Clinical Pastoral Education and your educational goals, including how this training will be used to meet your goals for doing ministry. An admissions interview by an ACPE Supervisor or another qualified person. (CPE Supervisors, Seminary Liaison Professors, and Regional Directors may recommend interviewer).   Admission Interview Conducted by: Address: Please attach a current resume. Those with previous CPE should complete the following: Copies of previous CPE evaluations written by you and your supervisor. What was the most significant learning experience in previous CPE and how have you continued to work in this learning method? Illustrate your strengths and weaknesses as a professional person. What are your personal and professional goals and how will continued training aid that process? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I certify that all information in this application is factually true, complete, and honestly presented. I understand that I may be subject to disciplinary action, including admission revocation or program expulsion, should the information I’ve certified be false. I hereby give permission to the ACPE center to which I am applying to access my CPE evaluations and contact previous supervisory personnel about matters pertaining to this current application, and I consent for those contacted to provide the information sought. Signature of Applicant: ____________________________________ Date: __________________________   Sign/date, and mail application to: Chaplain Jim Browning Department of Pastoral Care, Dulles 1 Hospital of the University of Pennsylvania 3400 Spruce Street Philadelphia, PA 19104 The UPHS CPE Center is accredited by The Association for Clinical Pastoral Education, Inc., (1545 Clairmont Rd., Suite 103, Decatur, GA 30033).