Virtual Practicum Student Application

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Child Life United Together

Virtual Practicum Student Application - ALL SECTIONS ARE REQUIRED

Personal Information

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Credentials *

Professional Memberships *

Documents

* Indicates required field

Cover Letter/ Statement of Interest *

Max file size: 20MB

Resume/ Curriculum Vitae *

Max file size: 20MB

Eligibility Document OR Proof of Completing Course Work *

Max file size: 20MB

Official ACLP Documentation of Volunteer Hours OR Verification from Volunteer Supervisor *

Max file size: 20MB

Professional Reference Letter #1 *

Max file size: 20MB

Professional Reference Letter #2 *

Max file size: 20MB

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

Please list all colleges/ universities.
If additional space is needed use comment box.

University Name *

Major *

Years attended/ Graduation *

GPA overall / GPA major *

Degree's *

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

COMMENT: List additional Academic Institutions *

Have you completed a course taught by a CCLS? This is a prerequisite and must be completed prior to the start of the virtual practicum. *

Yes No

Have you 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 stressful situation 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 *

Additonal 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? *

Briefly 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? *

Do you require financial assistance? *

Yes No

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

Submit

Services
About
- About Child Life United
- Team
Programs
Applications
Media
Contact
Child Life United Together

Personal Information

Documents

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

Additonal Work Experience

Essay Questions

EXPERIENCE WITH CHILDREN, YOUTH OR FAMILIES
Healthcare Setting

Experience with Children, youth or families
Stressful situations

Experience with Children, youth or families
Well Child