Application to Lead an Activity in the Spiritual Centre

Name*
First Last
Student Number
(if applicable)
Email*
Phone*
Type of Activity*
Select all that apply*
- Prayer
- Khutbah
- Meeting/discussion group
- Education
- Religious counselling
- Other
Please specify*
Please specify*
Description of Activity*
Frequency of Proposed Activity*
Preferred Day(s) and Time(s)*
Click the plus sign (+) to the right to add more days and times.
Day Time
Preferred Start Date*
MM slash DD slash YYYY
Number of Participants*
Minimum Maximum
Special Equipment Needed*
Do you represent a recognized religious or spiritual organization?*
Qualifications*
(certification, training, experience)
References*
Click the plus sign (+) to the right to add more references as required.
Full Name Position Phone Email
To ensure that all activities in the Spiritual Centre are equally accessible to all students, there shall be no solicitation of money for goods or services offered in the Spiritual Centre, and no solicitation of donations to individuals or organizations.

As an activity leader at Algonquin College’s Spiritual Centre, I agree to the following:

To uphold the values of caring, learning, integrity, and respect;
To ensure a healthy environment where each member of the Algonquin College community can practise spirituality freely and with integrity and respect;
To ensure that the practices and expressions of spirituality do not infringe on the rights of others or contravene any College policy.
I agree to the statement above*
- Yes
Date*
Month
Day
Year

Appendix 1
Request for Authorization to Engage in the Algonquin College Spiritual Centre

Algonquin College interviews and approves persons who wish to provide religious services and spiritual care in multi-faith environments. Based upon your training, experience, and the endorsement of your faith group, you will be assessed as to your suitability for such a volunteer position.

You are asked to complete this application form. If there are questions you are unable, or choose not to answer, please state the reasons.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Business Fax Home Cell
Languages Spoken Proficiently*
Ordaining/Commissioning Authority
(If applicable)
Name Date
Faith Group Authority*
Name Address Postal Code
Education*
Please select all that apply
- College or University
- Theological and/or Post-Graduate Studies
- Supervised Pastoral Education
- Faith Group or Religious Training
- Other
Please specify
College or University*
Click the plus sign (+) to the right to add more studies
Name and Location Major Subject Dates Attended Post-Secondary Degree Complete
Theological and/or Post-Graduate Studies*
Click the plus sign (+) to the right to add more studies
Name and Location Dates Attended Post-Secondary Degree Complete
Supervised Pastoral Education*
List in chronological order your four (4) most recent units of S.P.E. (either P.C.E. or C.P.E.) Click the plus sign (+) to the right to add more studies.
Centre Level Basic/Advanced Dates Attended Supervisor
Faith Group or Religious Training*
Click the plus sign (+) to the right to add more studies.
Name and Location Dates Attended Post-Secondary Degree Complete
Other related experiences that qualify you*
(Please describe)
Authorization (Full Name)*
Pursuant to Section 39(1) of the Freedom of Information and Protection of Privacy Act, I ( name in full) _________________________________ authorize Algonquin College and its staff to contact the person or organizations listed below for the purposes of obtaining reference information.
References
Spiritual Advisor or other person who will attest to spiritual/religious maturity:*
First Last
Position/Title*
Name of Organization*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
References
S.P.E. Supervisor or other person who will attest to clinical abilities:*
First Last
Position/Title*
Name of Organization*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
References
The person to whom you have sent the certificate of faith group endorsement:*
First Last
Position/Title*
Name of Organization*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Faith History Please briefly answer the following questions.
Give a brief background of your religious affiliation and personal faith development.*
Describe a personal understanding of a belief that comes directly from your faith tradition and how that belief has changed for you over time.*
Describe some of the cultural practices of your faith group or community and their significance and meaning for you.*
How do you deal with your faith group’s stance concerning other faith groups, when it is in conflict with your personal beliefs?*
I hereby declare that, to my knowledge, the foregoing information is true and complete, and if authorized to volunteer for Algonquin College’s Spiritual Centre, I approve my credentials and a brief biographical information be publicized in College communications regarding the Spiritual Centre.*
- I agree
Date*
Month
Day
Year
Are you applying for chaplaincy membership?*
Appendix 2
Certificate of Endorsement

If you are applying for chaplaincy membership, please ensure Appendix 2, “Certificate of Religious/Spiritual Group Endorsement” is completed by the Faith Group Authority indicated in Appendix 1 and returned to Algonquin College.

Appendix 2 can be found here, and will also be emailed to the applicant for completion by the Faith Group Authority once this form is submitted.

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Spiritual Centre

Application to Lead an Activity in the Spiritual Centre

Step 1 of 2

Appendix 1

Appendix 2

Ottawa

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Perth

Online

Name and Location	Major Subject	Dates Attended	Post-Secondary Degree Complete

Day	Time

Full Name	Position	Phone	Email

Centre	Level Basic/Advanced	Dates Attended	Supervisor