FIELD EDUCATION PLACEMENT APPROVAL REQUEST



lefttop00The Office of Field EducationPre-Enrollment Ministry Discernment Program for Contextual Learning STUDENT APPLICATION Date: Click here to enter a date.INTRODUCTION:This form provides the Office of Field Education with critical information pertinent to your summer placement. Please complete it neatly and accurately. PERSONAL DATA:Name: Click here to enter name.SS# Click here to enter your SS#.School Address: Current Address: (If different from school address)Click here to enter school address. Click here to enter current address.Phone:Click here to enter phone #. Phone: Click here to enter phone #.E-mail: Click here to enter best email address.Gender: Choose your gender. Date of Birth: Click here to enter date of birth.US Citizen? **Choose Yes or No **If you are NOT a US Citizen, you are not eligible for the Pre-Enrollment Ministry Discernment Program.Physical limitations that may influence your assignment: Click here to enter physical limitations.ETHNIC ORIGIN: Choose your ethnic origin.Marital status: Choose marital status. If engaged, wedding date Click here to enter date.Spouse’s full name Click here to enter spouse’s full name.No. of children Click here to enter # of children. Ages Click here to enter children’s age(s). Spouse’s occupation Click here to enter spouse’s occupation.If possible do you intend for your spouse to accompany you in this program? Click here to enter comments.Annual Conference Click here to enter your Annual Conference. Church membership Click here to enter where your church membership is located.Where do you attend church? Click here to enter the name of the church you are currently attending.Candidacy status: Click here to enter your candidacy status.Will you have a car in good operating condition for this program? Choose yes or no.Do you have health and accident insurance? Choose yes or no.INDICATE BELOW, IN RANK ORDER, WHICH AREAS OF MINISTRY PRESENTLY INTEREST YOU MOST:Choose a #parish ministry Choose a # campus ministry Choose a # teaching Choose a # urban ministry Choose a # missionsChoose a # institutional or military chaplaincy Choose a # Christian educationChoose a # other (please explain) Click here to enter explanation.Are there compelling personal circumstances or hardships which you feel must be considered for your participation in this program?Click here to enter comments.If accepted to this program, I covenant to accept the placement offered for this summer, matriculate at Duke Divinity School and take seriously the ministry exploration opportunities in this program insofar as my abilities permit with the support of the Office of Field Education. My signature authorizes the release of the data on this application to my pastor supervisor when my placement is announced and grants the field education staff full access to my Divinity School records for purposes of program participation. Signed ___________________________________________A. VITA:1. Name Click here to enter name.2. Educational experiences (post-high school)InstitutionDates attended Area(s) of concentration1. Click here to enter educational experience.2. Click here to enter educational experience.3. Click here to enter educational experience.4. Click here to enter educational experience.3. Extra-curricular Activities (explain, if necessary) in undergraduate education:Click here to enter extra-curricular activities.4. Church Experience (where, offices held, paid positions, special experiences, etc.)Click here to enter church experience.5. Work Experience (part-time and full-time employment of whatever kind during and following college; explain if necessary)Click here to enter work experience.6. Special skills you may have developed through church, educational or work experiences (for example, music, athletics, drama, organizational-management, etc.)Click here to enter special skills you may have.7. Hobbies and/or special interests (including significant travel experiences)Click here to enter hobbies and special interests.8. Do you have any foreign language facility? Choose Yes or No.What language(s)? Click here to enter foreign language(s).B. Faith Pilgrimage:On a separate sheet write a summary of your journey into ministry, including the pivotal influences on your decision to explore full-time Christian service and the high points of your spiritual and theological formation. One to two double-spaced pages should suffice. Note that after students are selected and supervisors are notified students are responsible for e-mailing the faith pilgrimage portion to the supervisor.Please complete this application by March 15 and fax it to the Office of Admissions 919.660.3535 or e-mail your completed application to admissions@div.duke.edu. ................
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