Mater Dei Institute of Education
A College of Dublin City University
Section B – Placement Proposal Form
PMA in Healthcare Chaplaincy 2015-2016
1 Year Full-Time
Notes: (1) The placement will be 18-20 hours per week. (2) Course participants will be required to attend 2 days of lectures per week, & 7 Saturdays. Please
keep this in mind when planning activities and meetings.
Applicant– please print details
Name of Applicant
Address of Applicant
Phone number of Applicant
Present Work Position
Address of Current Employer
Phone number of Current Employer
Placement Location- Where do you intend to complete your placement? Please select from list below:
1: General Hospital 2: Specialist Hospital 
3. Hospice 
4.Nursing Home 
5.Healthcare facility 
6. Other: Please Specify  ________________
Name of Placement Contact Person
Address of Chaplaincy Placement
Phone number of Contact Person
Name of Chaplain in Placement Location
Address of Chaplain in Placement Location
Phone number of Chaplain in Placement Location
Placement Facilitator:
Are you willing to accommodate the candidate by facilitating his or her placement as a Student Healthcare Chaplain? (Please circle)
Facilitator’s Signature and Role:
Date:
Applicant’s Signature:
Date:
Yes / No
This form should be completed and returned to the Admissions Office with the application. All placement proposals must be approved by the Institute.