Child Life Practicum Application

Date

Personal Information

First Name

Last Name

Email Address

Phone

Address

City

State

Zip

Emergency Contact

In case of emergency, notify:

Relationship

Address

City

State

Zip

Phone

Email Address

Undergraduate Education

College/University

Major

Cumulative GPA

Major GPA

Expected/Graduation Date

Graduate Education

College/University

Major

Cumulative GPA

Major GPA

Expected/Graduation Date

Please list completed courses relevant to Child Life practice. At least THREE are required.

At the start of the practicum semester you are applying for, what will be your academic standing?

Will you be receiving academic credit for your practicum?

If you will be receiving academic credit for your practicum, please provide the contact information for your university affiliate. (Name/title, College/University, email, phone number are required.) All students seeking credit for the program, must be sure that their University has a current affiliation agreement with Penn State Health.

If you have previously completed a Child Life Practicum or field placement in Child Life, please upload a copy of any evaluation form including the name of your supervisor.

Related Volunteer Experience

Name of Facility:

Position held/Department:

Dates of volunteering - to:

Dates of Volunteering - from:

Number of hours completed:

Responsibilities:

Work Experience

Name of Facility:

Dates of Hire - From:

Dates of Hire - To:

Dates of Hire - From:

Position held/Department:

Responsibilities:

Please list any activities/professional and student organizations/certifications.

Please explain if you will have any additional commitments during the times of the practicum.

Why are you interested in the field of Child Life and what are your future goals within the field?

What interests you most about doing your practicum at Penn State Health Children's Hospital?

What do you feel you can bring to our practicum program?

Please upload all academic transcripts.

Please upload your resume.

Contact Information