Introduction to Spiritual Care Course: (to which this application relates)Intro to Spiritual Care Course Location/Mode*Please select.....OnlineCommencement Date* DD slash MM slash YYYY Supervisor/s*Please select....Trish ByrneApplicant's personal detailsName* First Last Title*Please select.....MrMrsMsMissRevPastorSisterFatherOtherAddress* Street Address City ZIP / Postal Code Email* Phone - mobile*Date of birth* MM slash DD slash YYYY Place of birth*Marital status*Spiritual AffiliationDenomination/Faith Affiliation*Name of parish priest/minister/leader/Guru/Master*PhoneRelevant TrainingMost recent firstCourse #1Institution #1Length #1Date of award #1 DD slash MM slash YYYY Course #2Institution #2Length #2Date of award #2 DD slash MM slash YYYY Theological/Spiritual Education (if not cited above)CourseInstitutionLengthDate of award DD slash MM slash YYYY Details of any Spiritual Care or CPE applications previously declined or currently being processedPast Experience of MinistryDescriptionLocationDatesHrs/weekPresent Ministry/Pastoral WorkDescriptionLocationDatesHrs/weekPresent Pastoral Responsibilities/Roles: (give details)Reasons for lodging this application:Other Information: (considered relevant to this application)Referee: (one required from present faith/spiritual community)#1 Name*Relationship to you*#1 Phone*Autobiographical Account (1500 words MINIMUM)A reflective and reasonably full account of your life, including important events and relationships, and the effects of these significant relationships and events on your emotional, social and spiritual development.*One thing you hope to gain by completing this Intro to Spiritual Care course (approximately 100 words)What are you hoping to learn in attending this course:*Documents to accompany application form:Documents to be emailed to info@qicpe.com to accompany application Evidence of payment of non-refundable application and processing fee of $50 ($51.19 if paying by credit card). See below.$50 ($51.19 by credit card)Application and Processing Fee (non-refundable) Payment method*Please choose from Drop Down list:Credit Card on QICPE website ($51.19)Direct Deposit to QICPE Inc, BSB: 034072, A/C No: 186321Deposit at Westpac bank: QICPE Inc, BSB: 034072, A/C No: 186321Application and Processing fee is required before submitting this application.Permission for restricted access for my contact details:As part of my application, I give my permission for my name, mobile number and email address to be accessed by the QICPE Secretary and Treasurer for the purposes of facilitating official QICPE processes (e.g. invoicing, membership matters, invitations to QICPE functions etc.)* YesAfter receipt of your fully completed application and non-refundable application fee, you will be notified of the outcome. If successful, you will offered a place in the course, and then invoiced for $500 which is payable BEFORE the Introduction to Spiritual Care course commences.I acknowledge I have read the above information.* Yes
