香港中文大學崇基學院神學院實習教育修讀申請表 The Chinese University of Hong Kong Divinity School of Chung Chi College Field Education Application Form

注意：
♦ 此報名表必須於建議之實習期開始前兩個月或前填妥及交回神學院實踐教育主任。
♦ 四及五年制之神道學學士生，如要修讀「學期全時間實習」，必須於四年級下學期至暑假修讀。

Remark:
• Students are advised to submit their fieldwork application form AT LEAST TWO MONTHS IN ADVANCE to the Practical Education Co-ordinator for approval.
• For students in the BD 5-yr programme, full-time Field Education should be arranged in the 2nd term of the fourth year, usually from January to August.

姓（英文）
Surname in English
名（英文）
Given names in English
姓名（中文）（如適用）
Name in Chinese (if applicable)
Program 修讀課程
B.D. Study Year 年制

B.D. Study Year 年制 3 4 5
Year 年級

Year 年級 1 2 3 4 5
地址
Mailing Address
Phone 電話
Email 電郵
副修（如適用）
Minor (if applicable)
前獲取之學歷
Academic Qualification
主修
Major
所屬教會／堂會
Affiliated Church
曾擔任之事奉崗位
Position(s) served
是否曾於本神學院實習? (如有, 請提供下列資料)
Did you participate in the field education program of Divinity School of Chung Chi College?
(If yes, please provide details below)

是否曾於本神學院實習? (如有, 請提供下列資料) Did you participate in the field education program of Divinity School of Chung Chi College? (If yes, please provide details below) Yes No
課程編號 Course code
實習期開始日期 Period Start Date 實習期開始日期 Period Start Date / MM / DD YYYY
實習期結束日期 Period End Date 實習期結束日期 Period End Date / MM / DD YYYY
所屬教會／堂會
Affiliated Church
工作性質 Responsibilities
已修讀之科目
Courses taken
實習建議
Placement Proposal

實習建議 Placement Proposal 堂會／機構臨床牧養教育訓練課程(CPE) 普世合一社會牧職暑期實習計劃
CPE課程機構

CPE課程機構雅麗氏何妙齡那打素醫院牧關事工香港醫院院牧事工聯會明華神學院天主教香港教區醫院牧民委員會其他機構其他機構
建議實習堂會／機構
Proposed Church / institution
建議開始實習期 Proposed Period Start Date 建議開始實習期
Proposed Period Start Date / MM / DD YYYY
建議完結實習期 Proposed Period End Date 建議完結實習期
Proposed Period End Date / MM / DD YYYY
建議實習導師
Proposed Placement Supervisor

This is the description of your section break.
稱呼 Title
姓（英文）
Surname in English
名（英文）
Given names in English
姓名（中文）（如適用）
Name in Chinese (if applicable)
堂會／機構（如與上不同）
Church / institution (if different from above)
地址
Mailing Address
電話
Contact number
電郵
Contact Email
Disclaimer The personal data collected will be used by Divinity School of Chung Chi College (DIVSCH_CC) and authorised personnel for processing the captioned purposes in accordance with relevant provisions of the Personal Data (Privacy) Ordinance.

香港中文大學崇基學院神學院實習教育修讀申請表 The Chinese University of Hong Kong Divinity School of Chung Chi College Field Education Application Form

建議實習導師 Proposed Placement Supervisor

建議實習導師
Proposed Placement Supervisor