Virtual Practicum Student Application

Virtual Practicum Student Application - ALL SECTIONS ARE REQUIRED

Application for CLU Fall 2023 Virtual Practicum
Practicum dates are September 11-November 13
Applications are due on July 23rd

Personal Information

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Credentials *

Professional Memberships *

Documents
(ALL DOCUMENTS MUST BE SUBMITTED IN PDF FORMAT TO BE ACCEPTED)

* Indicates required field

Cover Letter/ Statement of Interest *

Max file size: 20MB

Resume/ Curriculum Vitae *

Max file size: 20MB

Eligibility Document (through ACLP) OR Proof of Completing Course Work (CLU accepts unofficial transcripts) *

Max file size: 20MB

Documentation of Volunteer Hours OR Verification from Volunteer Supervisor (This can be the ACLP form or a professional statement on any organizational letterhead) *

Max file size: 20MB

Two Letters of Recommendation are required for your application to be considered.
Please have your references email your recommendation letters to [email protected] with your name in the subject line.

We will also allow you (as the applicant) to submit the recommendation letters if you have them in your possession from previous applications
(please email to[email protected] with your name in the subject line).

Emergency Information

Emergency Contact / Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Languages

Primary / 1st Language *

other languages and degree of skill (Learning, Basic, Fluent)

#1 *

#2 *

#3 *

Academic Information

Use the space below to state the highest level of education (in process or completed).

University Name *

Graduation Date or Anticipated Graduation Date *

GPA overall / GPA major *

Major *

Degree's *

Associate's Degree Bachelor's Degree Master's Degree PhD

COMMENT: Please list all additional Academic Institutions and degrees *

By the start of the practicum will you have completed the required introductory child life course taught by a CCLS? This is a prerequisite and must be completed prior to the start of the virtual practicum. *

Yes No

By the start of the practicum will you have completed at least one child development course? This is a prerequisite and must be completed prior to the start of the virtual practicum. *

Yes No

EXPERIENCE WITH CHILDREN, YOUTH OR FAMILIES
Healthcare Setting

Please list all healthcare experiences (volunteer, practicum student). If additional space is needed use comment box.

Institution Name *

Title (e.g volunteer, practicum student) *

Supervisor's Name/ Credentials/ Title *

Supervisor's Phone Number *

Dates mm/yr *

Hours/Week *

# of Weeks *

Total Hours *

Briefly describe population and responsibilities *

Experience with Children, youth or families
Stressful situations

Please list all stressful situation experiences (camps for children with chronic illness, programs for children with special needs, advocacy programs, bereavement/ hospice).

Institution Name *

Title (e.g. volunteer, practicum student) *

Supervisor's Name/ Credentials/ Title *

Phone Number *

Dates mm/yr *

Hours/ Week *

# of Weeks *

Total Hours *

Briefly describe population and responsibilities *

Experience with Children, youth or families
Well Child

Please list all well child experiences (nanny, counselor, teacher).

Institution Name *

Title (e.g. volunteer/ practicum student) *

Supervisor's Name/ Credentials/ Title *

Phone Number *

Dates mm/yr *

Hours/ Week *

# of Weeks *

Total Hours *

Briefly describe population and responsibilities *

Additional Work Experience

Institution *

Title (e.g volunteer/ practicum student) *

Supervisor's Name/ Creditionals/ Title *

Phone Number *

Dates mm/yr *

Hours/ Week *

# of Weeks *

Total Hours *

Briefly describe population and responsiblities *

Essay Questions

What have you done to increase your knowledge/ awareness of this profession? *

Describe the ways in which the work of a Child Life Specialist contributes to the health care experience of a child and their family. *

Provide a specific example of a time that you used play to meet the developmental needs of a child. *

Is there any additional information you would like to share? *

Financial Assistance

Do you require financial assistance? *

Yes No

If you choose yes to this question, please copy and paste the following link into another tab on your browser. Please ensure to submit the current practicum application prior to moving onto the google form which is our needs based scholarship application. *Note- the scholarship application is also due on 7/23.
https://forms.gle/GBv5puBkGDPu31qP7

by electronically submitting your name you attest that this application is true and accurate to the best of your knowledge - SIGN HERE *

Submit

Application for CLU Fall 2023 Virtual PracticumPracticum dates are September 11-November 13Applications are due on July 23rd

Personal Information

Documents ​(ALL DOCUMENTS MUST BE SUBMITTED IN PDF FORMAT TO BE ACCEPTED)

Emergency Information

Languages

Academic Information

​EXPERIENCE WITH CHILDREN, YOUTH OR FAMILIES Healthcare Setting

Experience with Children, youth or families Stressful situations

Experience with Children, youth or families Well Child

Additional Work Experience

Essay Questions

Financial Assistance

Application for CLU Fall 2023 Virtual Practicum
Practicum dates are September 11-November 13
Applications are due on July 23rd

Documents
(ALL DOCUMENTS MUST BE SUBMITTED IN PDF FORMAT TO BE ACCEPTED)

EXPERIENCE WITH CHILDREN, YOUTH OR FAMILIES
Healthcare Setting

Experience with Children, youth or families
Stressful situations

Experience with Children, youth or families
Well Child