Participant Application
KPCC Clergy Training Program

Name ______________________________________     Date __________________________

Address _____________________________________________________________________

Day Phone ______________________                              Cell Phone ______________________ 

Night Phone _____________________                              Fax ____________________________

E-mail __________________________

Church ______________________________________________________________________

Church Address _______________________________________________________________

Ordination Date and Denomination ________________________________________________

Highest Degree and Institution ___________________________________________________

How did you hear about our program?

What particularly interests you about the program?

Complete applications include:

1. A resume
2. A letter of reference
3. A brief statement of interest (no more than three pages), which includes
            A. Your previous clinical experience
            B. An experience in the past year that has had an impact on you
            C. Two authors/artists who have influenced you
            D. Describe three of your strengths and three growing edges
            E. Your initial learning goals
4. Full tuition of $300. Checks can be made out to KPCC.
            Applicants who are not accepted into the program will receive a full refund.

Please print out this application and submit all application materials at one time to:
Dr. Sky Kershner, Director KPCC, 16 Leon Sullivan Way, Charleston, WV 25301.