<p> FOR OFFICE USE ONLY:</p><p>BEESON DIVINITY SCHOOL  PROPOSAL APPROVED Samford University  RECORDED IN SYSTEM MINISTRY LEADERSHIP DEVELOPMENT</p><p>SUPERVISED MINISTRY PRACTICUM PROPOSAL FORM</p><p>Date: ______</p><p>Please indicate the format for this practicum:</p><p>Continuous-year practicums </p><p>_____ Practicum embedded in course requirements of DVML 625 (fall) and DVML725 (spring)</p><p>Clinical Pastoral Education (CPE)</p><p>_____ DVML 751 Clinical Pastoral Education – 3 credits</p><p>_____ DVML 551 Clinical Pastoral Education 1 – 1 credit</p><p>_____ DVML 651 Clinical Pastoral Education 2 – 2 credits</p><p>Please indicate academic term for this CPE course (circle one):</p><p>Summer Fall Spring</p><p>STUDENT INFORMATION</p><p>Name: ______</p><p>Address: ______Street City State Zip</p><p>Phone #: ______E-mail Address (most used): ______PLACEMENT INFORMATION </p><p>Placement where practicum will occur: ______</p><p>Address: ______Street City State Zip Phone #: ______</p><p>Position: ______Remuneration (paid): Yes / No</p><p>Projected Start Date: ______</p><p>Please provide a detailed description of ministry responsibilities/opportunities AND anticipated weekly schedule.</p><p>MENTOR INFORMATION</p><p>Name (with title): ______</p><p>Position: ______Time at this position: ______</p><p>Address (if different from Placement Information): ______Street ______Phone (if different): ______City State Zip</p><p>E-mail Address: ______</p><p>I have provided the prospective mentor with a copy of “Guidelines for Mentors,” and have discussed with her/him the Divinity School’s expectations of mentors, as well as my needs and goals for the practicum experience. The prospective mentor has given initial consent to serve in this capacity for the duration of the upcoming academic term (semester or year).</p><p>PLEASE ATTACH A COPY OF YOUR MENTOR’S RÉSUMÉ. (A résumé is not needed if the MLD Office has a current résumé on file for your mentor.)</p><p>This information will be reviewed by the MLD Director, who reserves the right to reject or approve all practicum placement sites and/or mentors.</p><p>Approved</p><p>______Signature of MLD Director Date</p>