Office of Educational and Synodical Placement
Office of Synodical Placement
Concordia University Chicago, River Forest, IL
Concordia University System
SYNODICAL PLACEMENT APPLICATION
Name
LastMaidenFirstInitial
Home Address
Street AddressCityStateZip Code
Church Membership
NameCityStateLCMS District
Personal Email Concordia Email crf_ @cuchicago.edu
Cell Phone (
Home Phone ( FORMTEXT
) )
Other Phone ( )
Program FORMCHECKBOX Early Childhood FORMCHECKBOX BME
FORMCHECKBOX DCE/Single Cert
FORMCHECKBOX Early Childhood/Elem FORMCHECKBOX DPM FORMCHECKBOX
DCE/Elementary
FORMCHECKBOX Elementary FORMCHECKBOX Art FORMCHECKBOX
DCE/BME
FORMCHECKBOX Middle FORMCHECKBOX Physical Ed FORMCHECKBOX
Deaconess
FORMCHECKBOX Secondary FORMCHECKBOX Spec Ed FORMCHECKBOX
Colloquy
G.P.A. FORMCHECKBOX 2.00-2.49 FORMCHECKBOX 2.50-2.99
FORMCHECKBOX 3.00-3.49 FORMCHECKBOX 3.50-4.00
Anticipated Date of Graduation FORMCHECKBOX Fall FORMCHECKBOX
Spring FORMCHECKBOX SummerYear FORMDROPDOWN
High School(s) Attended
NameCity
State
NameCityState
Colleges/Universities Attended
FORMDROPDOWN
Concordia University ChicagoRiver ForestIL
DegreeNameCityStateInclusive Dates (mm/yyyy)
DegreeNameCityStateInclusive Dates (mm/yyyy)
DegreeNameCityStateInclusive Dates (mm/yyyy)
Type of Teaching Certificate (Lutheran Teacher or
dual-certification DCE only)
FORMCHECKBOX Early Childhood FORMCHECKBOX Elementary K-9
FORMCHECKBOX Secondary 6-12 FORMCHECKBOX K-12
Additional Certificate(s)/ Endorsement(s):
FORMCHECKBOX Administrative FORMCHECKBOX Middle School
FORMCHECKBOX School Service FORMCHECKBOX Other
Academic Program
UndergraduateMajor
Minor
Endorsements
Major/Concentration CoursesSemester Hours
Minor/Theology Endorsement Courses
Christian Life3
History of Christian Biography2
Introduction to Lutheran Theology3
Introduction to the New Testament3
Introduction to the Old Testament3
Spiritual Nurture: Elem School Child3
Spiritual Nurture of the Adolescent3
World Religions3
Student Teaching
adjust the above as necessary
EXPERIENCE:
Student Teaching
Site
SchoolCityState
Grade Level(s)
FORMCHECKBOX Fall FORMCHECKBOX Spring Year FORMDROPDOWN
Cooperating Teacher(s) ( )
Name Phone
University Supervisor ( )
Name Phone
Site
SchoolCityState
Grade Level(s)
FORMCHECKBOX Fall FORMCHECKBOX Spring Year FORMDROPDOWN
Cooperating Teacher(s) ( )
Name Phone
University Supervisor ( )
Name Phone
Previous Full-Time Professional Experience
Congregation/School/AgencyCityStateInclusive Dates (mm/yyyy)
Congregation/School/AgencyCityStateInclusive Dates (mm/yyyy)
Congregation/School/AgencyCityStateInclusive Dates (mm/yyyy)
Interests (Personal/Recreational Interests, not necessarily
related to professional training.)
1.
2.
3.
References
The following individuals can attest to the candidate's
qualifications for ministry, professional strengths and Christian
character and may be contacted by prospective employers:
( )
NameTitle/Relationship to CandidatePhone
( )
NameTitle/Relationship to CandidatePhone
( )
NameTitle/Relationship to CandidatePhone
LEADERSHIP SKILLS:
Indicated below are areas in which I can take a leadership
role:
Training - was part of my professional training
Experience - have experience to a significant degree
Interest - have future interest, whether through advanced
education or voluntary participation
.
Age/Grade Level/Groups
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Childcare/Infant/Tod/PK
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Childcare/School
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Pre-School Age 3
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Pre-School Age 4
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Kindergarten
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Grade 1
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Grade 7
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Grade 8
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Grade 9
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Grade 10
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Grade 11
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Grade 12
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Multi-Grade (any)
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Multi-Grade (middle)
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Higher Education
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Adult
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Disabled
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District/Synod
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ESL
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Seniors
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Singles
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Special Education
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Youth Jr High
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Youth Sr High
Elementary and/or Secondary
T
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Art (ceramics/sculpt)
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Art (drawing)
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Art (general)
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Art (graphics)
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Art (painting)
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Business Ed
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Computer Ed
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Economics (consumer)
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Economics (general)
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English (AP)
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English (composition)
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English (gen/sec)
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English (literature)
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ESL
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Geography
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Government
Foreign Languages
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French
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German
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Latin
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Spanish
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Other
T
E
I
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History (general)
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History (AP)
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Home Economics
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Industrial Tech
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Language Arts (ele)
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Math (adv trg/calc/AP)
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Math (basic alg/geo)
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Math (general)
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Music Instrument (ele)
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Music Instrument (sec)
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Music (Instrument
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Music Vocal (ele)
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Music Vocal (sec)
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Outdoor Education
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Physical Education (ele)
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Physical Education (sec)
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Political Science
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Psychology
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Reading
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Reading (study skills)
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Religion
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Science (AP bio/anat)
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Science (AP chem)
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Science (AP physics)
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Science (bio)
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Science (chem)
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Science (earth)
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Science (general)
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Science (physics)
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Social Studies
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Sociology
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Speech
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Theater
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Theology
Special Education
T
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I
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Attention Deficit
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Autistic
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Behavior Disordered
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Cross Categorical
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Hearing Impaired
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Learning Disabled
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Physically Disabled
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Visually Impaired
Coaching
T
E
I
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Athletic Director (ele)
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Athletic Director (sec)
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Coaching Males
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Coaching Females
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Coaching Either
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Baseball (fr/so)
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Baseball (varsity)
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Basketball (ele)
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Basketball (fr/so)
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Basketball (varsity)
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Cheer/Poms (ele)
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Cheer/Poms (sec)
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Cross Country (ele)
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Cross Country (fr/so)
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Cross Country (varsity)
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Football (ele)
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Football (fr/so)
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Football (varsity)
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Golf (fr/so)
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Golf (varsity)
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Soccer (ele)
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Soccer (fr/so)
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Soccer (varsity)
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Softball (ele)
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Softball (fr/so)
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Softball (varsity)
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Swimming
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Tennis (fr/so)
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Tennis (varsity)
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Track & Field (ele)
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Track & Field (fr/so)
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Track & Field (varsity)
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Volleyball (ele)
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Volleyball (fr/so)
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Volleyball (varsity)
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Wrestling (fr/so)
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Wrestling (varsity)
Extra Curricular Activities and Service
T
E
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Alumni Events
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Awards Committee
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Boosters
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Career Day
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Community Service
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Computer Club
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Drama
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Faculty Events
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Faculty In-Service
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Forensics Team
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Language Clubs
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National Honor Society
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Peer Counseling
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Peer Tutoring
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Publications Newspaper
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Publications Yearbook
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School Calendar
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Science Fair
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Service Activities
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Special Interest Clubs
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Special Event Planning
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Student Exchange
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Student Government
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Other
Administration
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Deaconess
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Dean of Chapel
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Dean of Students
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Department Chair
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Dir Admissions
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Dir Adult Ministry
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Dir Camp Ministry
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Dir Campus Ministry
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Dir Children’s Ministry
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Dir Christian Education
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Dir Christian Outreach
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Dir Church Music
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Dir Early Childhood
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Dir Family Ministry
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Dir Media Services
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Dir School Counseling
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Dir Student Activities
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Dir Parish Music
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Dir Singles Ministry
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Dir Youth Ministry
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Principal (elementary)
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Principal (secondary)
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Principal (assistant)
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Registrar
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School Counselor
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Testing Coordinator
Parish-Wide Leadership
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Adult Education
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Bible Class (adult)
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Bible Class (youth)
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Community Programming
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Computer Technology
Networking
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Confirmation Class
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Contemporary Worship
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District Board/Committee
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Evangelism/Outreach
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Fund Raising
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Interdenominational Programming
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Midweek School
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Parish Administration
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Parish Communication Public Relations
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Parish Social Activities
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Photography
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Scouts (boy)
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Scouts (girl)
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Senior Citizen Programs
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Singles Ministry
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Small Group Ministry
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Social Ministry
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Sunday School
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Traditional Worship
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Urban Ministry
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Vacation Bible School
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Video Technology
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Volunteer Coordination
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Youth Ministry Jr High
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Youth Ministry Sr High
Parish Music
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Band
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Choir (adult)
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Choir (children’s)
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Choir (general)
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Choir (youth)
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Drums
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Guitar
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Hand Bells
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Instrumental (accomp)
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Instrumental (ensemble)
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Keyboard
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Orchestra
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Organist
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Pianist
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School Classroom
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Sound Technician
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Worship Planning
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Other:
LCMS Districts
(rank: 1, 2, 3)
Atlantic
Calif/Nev/Hawaii
Pacific Southwest
Eastern
English
Florida/Georgia
Illinois Central
Illinois Northern
Illinois Southern
Indiana
Iowa East
Iowa West
Kansas
Michigan
Mid-South
Minnesota North
Minnesota South
Missouri
Montana
Nebraska
New England
New Jersey
North Dakota
Northwest
Ohio
Oklahoma
Rocky Mountain
South Dakota
Southeastern
Southern
Texas
Wisconsin North
Wisconsin South
Wyoming
SELC
All of the Above
Foreign Missions
Community
(rank: 1, 2, 3)
Large Metro
Small Urban
Suburban
Small Town
Rural
Multi-Cultural
Central City
All of the Above
Philosophy of Ministry Essay
Following is a brief essay, including factors which have
contributed to the candidate's interest in and attitude toward the
ministry of the Lutheran Teacher, DCE, Deaconess or Parish
Music.
Type your essay first as a new/separate document in Word, spell
check and then copy and paste it here
Initials _ _ Signature
Date
A signed copy of this form is on file in the CUC Placement
Office
Deaconess Supplementary Data
Program:
FORMCHECKBOX Undergraduate FORMCHECKBOX Deaconess Colloquy
FORMCHECKBOX Deaconess Chaplaincy
Deaconess Minor:
FORMCHECKBOX Biblical Languages FORMCHECKBOX Church Music
FORMCHECKBOX Psychology
FORMCHECKBOX Social Work FORMCHECKBOX Sociology FORMCHECKBOX
Other:
Field Work Experience(s)
Site:
Inclusive Dates:
Summary of Activity:
Site Supervisor ( )
NameTitlePhone
Site:
Inclusive Dates:
Summary of Activity:
Site Supervisor ( )
NameTitlePhone
Site:
Inclusive Dates:
Summary of Activity:
Site Supervisor ( )
NameTitlePhone
Internship:
Site:
Inclusive Dates:
Summary of Activity:
Site Supervisor ( )
NameTitlePhone
