APPLICATION CHECKLIST REVIEW
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1 APPLICATION CHECKLIST REVIEW COMPLETED AND SIGNED CHILD LIFE PRACTICUM APPLICATION PROFESSIONAL RESUME DOCUMENTED PROOF OF HOSPITAL/ HEALTHCARE EXPERIENCE DOCUMENTED PROOF OF EXPERIENCE WITH HEALTHY CHILDREN COPY OF CURRENT TRANSCRIPT 2 PROFESSIONAL RECOMMENDATION FORMS VERIFICATION FORM OF CHILD LIFE RELATED COURSES (3 TAL) VERIFICATION FORM OF CHILD LIFE SPECIALIST TAUGHT COURSE COMPLETED ESSAY RESPONSE QUESTIONS I attest that the information in this application is true and accurate to the best of my knowledge. Signature: : COMPLETED APPLICATIONS SHOULD BE MAILED : Child Life Department Child Life Practicum Program Supervisor Children s Memorial University Medical Center 3 rd Floor Pediatrics 4700 Water s Avenue Savannah, GA 31403
2 CHILD LIFE PRACTICUM SESSION SELECTION (Please rank choices 1 to 3) Please rank child life practicum sessions in order of choice (1 First choices through 3 - Last choice; Do not rank if unable to attend session): Session # 1 (Begins 2 nd Week in May) Session # 2 (Begins 2 nd Week in June) (The child life department cannot guarantee each applicants 1 st choice of child life practicum session) Personal Information Last Name First Name (M.I.) Social Security Number Present Phone Permanent Phone Address Present Address Permanent Address City State/Province ZIP Code Country City State/Province ZIP Code Country In case of emergency, notify: Emergency Contact Name Relationship Address Home Phone Work Phone City State/Province ZIP Code Country University-affiliated: Academic Information University Supervisor/Advisor Name Address Phone University Name University Department Address Please list ALL colleges and universities attended: 1. College/University Name City, State/Province s Attended ( mm/year) Graduation (mm/year) (include anticipated as well as official) Major Level: Bachelor s Master s Check one of the above GPA Cum GPA in Major 2. College/University Name City, State/Province s Attended ( mm/year) Graduation (mm/year) (include anticipated as well as official) Level: Bachelor s Master s Major
3 1. Experience with Children in Healthcare Settings Institution Supervisor s Name and Credentials Position Title (e.g., volunteer, practicum student) 2. Institution Supervisor s Name and Credentials Position Title (e.g., volunteer, practicum student) 1. Child-Related Experiences (i.e., child care, camps, education/teaching) Organization/Employer Position Title (e.g., nanny, teen counselor, teacher) Supervisor s Name 2. Organization/Employer Position Title (e.g., nanny, teen counselor, teacher) Supervisor s Name 3.
4 Organization/Employer Supervisor s Name Position Title (e.g., nanny, teen counselor, teacher) 4. Organization/Employer Position Title (e.g., nanny, teen counselor, teacher) Supervisor s Name Professional Involvement Please list the names of any professional/ school organizations you are a member of:
5 Professional Recommendation Form This applicant has applied for acceptance into the Child Life Practicum Student Program at the Children s Hospital at Memorial University Medical Center. This individual will be participating in a learning experience within a large medical facility serving pediatric patients and their families. Please classify the applicant s skill, knowledge, abilities and performance in regards to the below skills Applicant s Name Factors Outstanding Above Average Average Below Average Unsatisfactory Customer Service Resourcefulness Independence Motivation to learn Problem Solving Skills Acceptance and integration of constructive feedback Flexibility Interpersonal skills and interactions with children Responses to Stress Verbal communication skills Written communication skills Overall performance Please give at least 2 examples of this applicant s strengths. Please give at least 2 examples of this applicant s areas of improvement. Signature of Reference Relationship to Applicant Phone Number Address Please return to student in sealed envelope. Must be submitted with entire application packet to be accepted.
6 Child Life Taught Course Verification Form This applicant has applied for acceptance into the Child Life Practicum Student Program at the Children s Hospital at Memorial University Medical Center. In order to verify the applicant s eligibility for the program, each applicant must complete a minimum of one course taught by a Certified Child Life Specialist. Please verify that this applicant has completed or will be completing prior to Summer Semester by completing the information below: Applicant s Name Course Title Semester Completed Year Grade Received Yes Currently Enrolled Completion Signature of Advisor/ Professor Phone Number Address Please return to applicant. Must be submitted with entire application packet to be accepted.
7 Child Life Related Courses Verification Form This applicant has applied for acceptance into the Child Life Practicum Student Program at the Children s Hospital at Memorial University Medical Center. In order to verify the applicant s eligibility for the program, each applicant must have completed at least three college level courses required for child life certification eligibility through the Child Life Council. These courses can include: child development courses, child life theory or application courses, developmental psychology courses, family systems courses, or other child life related course. Please verify that this applicant has completed or will be completing these courses prior to Summer Semester by completing the information below: Applicant s Name Course Title Semester Completed Year Grade Received Yes Currently Enrolled Completion Signature of Advisor/ Professor Phone Number Address Please return to applicant. Must be submitted with entire application packet to be accepted.
8 Please answer the following questions: Essay Questions Discuss your reasoning for applying for the child life practicum experience at the Children s Hospital at MUMC. In your own words, discuss the following: What is a Child Life Specialist? Briefly discuss why you have chosen child life as a career choice. Provide a specific example of a time that planned and implemented developmentally appropriate activities for an individual child or a group of children.
9 Briefly describe a time when you provided developmentally interventions/ play for a child diagnosed with special needs, disability, or who has diagnosed limitations due to illness. Briefly discuss how hospitalization and/or illness affects a child s developmental progress. Describe the role of a child life practicum student in the clinical setting. Discuss your expectations and goals for the child life practicum experience.
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