Supervisor Membership Renewal/Application | Qld Institute of Clinical Pastoral Education

Supervisor Membership Application/Renewal (1)

We welcome you to join QICPE. The membership fee is $30 per year ($31 if paying by credit card.)

Member Title*
First Name*
Surname*
Address Line 1
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Address- Suburb/Town*
State*
Postcode*
Please enter a number from 0000 to 9999.
Mobile Telephone*
Email*
CPE Units conducted and completed since the last AGM - Include location, number of participants finishing, mode (eg F-T, P-T)*
For Lapsed Supervisors: Please provide a name and phone number of the current QICPE R and C Chair to nominate you for supervisory membership.
Mandtory Declaration*
- As a CPE Supervisor member of QICPE Inc, I have read and will abide by the QICPE Inc Code of Ethics and Professional Practice for Supervisory members (QICPE Standard 9.5) as found at https://qicpe.com/curriculum/
Declaration of Professional Conduct*
- I declare that no formal complaints have been received against me in the previous 12 months.
- I declare that a formal complaint is currently being investigated.
- I declare that a formal complaint has been investigated and I provide a summary of the outcome.
Declaration of Professional Development*
- I declare that I have completed the required hours of professional development for my accreditation status, that these records are kept in a logbook and that I will send this logbook to the R and C Chair.
- I have been unable to complete the required hours of professional development in the past 12 months.
I have not completed the required hours of Professional Development for the following reason/s:
One Year Membership
Price:
$50 if paid by Direct Deposit or cheque. $51 if paid by credit card online.
Payment Method*
Please advise our Treasurer, Trish, of any payments via email: treasurer@qicpe.com
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