PLTS CPE Notification & Scholarship Application

Student Information

First Name

Last Name

Student ID

Email Address

Program

If other, please name:

Site Information

Please send your CPE offer letter/email to contexted@plts.edu

CPE Site

City, State of Site

CPE Educator Name

Start Date

End Date

Kind of CPE program?

What type of CPE program are you enrolling in?

Has your candidacy committee approved online CPE?

Yes

No

Where / how will you complete your pastoral / spiritual care hours?

Costs during CPE:

I would like to be considered for a CPE scholarship

Yes

No

Will you take leave from employment during CPE?

Will you relocate for CPE?

Does your site offer a stipend?

Yes

No

Stipend Amount:

CPE Site Fee

Travel to/from CPE site:
approx total for entire
term of CPE

Moving costs

Housing costs

What are your housing plans?

Address During CPE (if known)

Country

Street

City

Region

Postal Code

By placing my name below, as a digital signature, I confirm that all above information is correct to the best of my knowledge. I also agree to send my final self and supervisor evaluations to the PLTS Office of Contextual Education, to be kept on file. These evaluations might be shared with select PLTS faculty for candidacy purposes.

No grade will be given for CPE until all evaluations are on file at PLTS.

Student Signature