Child Life Program - Morgan Stanley Children's Hospital

Child Life Program
Morgan Stanley Children’s Hospital
Practicum Application
PLEASE PRINT OR TYPE:
NAME:___________________________________________________
(LAST) (FIRST) (MIDDLE)
SOCIAL SECURITY NUMBER:__________________________________
PERMANENT ADDRESS:
______________________
______________________
______________________
PHONE#_______________
IN CASE OF EMERGENCY NOTIFY:
NAME:_____________________
ADDRESS:__________________
___________________
___________________
INTERNSHIP ADDRESS:
_______________________
_______________________
_______________________
PHONE #________________
RELATIONSHIP:____________
HOME #:________________
WORK #:________________
1) What practicum session are you applying for________________
2) Education:
Graduate College or
University____________________________________________
Address______________________________________________
Faculty Advisor__________________Phone#________________
Dates Attended__________________Major/Minor____________
Undergraduate College or
University____________________________________________
Address______________________________________________
Faculty Advisor__________________Phone #_______________
Dates Attended__________________Major/Minor____________

3) Experiences:
For each experience with children, list the
organization’s title, address, population and capacity in which
you interacted with this population. For this practicum you are
required to have100 hours of volunteer experience within a
healthcare setting.
Student Teaching / Fieldwork Experiences:
a._________________________________________________
_________________________________________________
_________________________________________________
b._________________________________________________
_________________________________________________
_________________________________________________
Volunteer Experiences:
a.__________________________________________________
__________________________________________________
__________________________________________________
b.__________________________________________________
__________________________________________________
__________________________________________________
4) Professional Organizations:
List all organizations that you belong to:_________________
_________________________________________________
_________________________________________________

5) Will you have any other commitments during your practicum If
yes, please describe____________________________________
____________________________________________________
____________________________________________________
6) Credentials:
An official transcript is required from each college / university
attended. Have you requested that transcripts be sent
Yes / No
If you have not had any Child Life course work, please describe
any relevant courses:
__________________________________________________
__________________________________________________
__________________________________________________
7) Essay:
Choose one of the following essay topics and attach your
essay on a separate page.
1. What are your goals for this practicum How do you
believe a practicum at MSCHONY can help you meet these
goals
2. Describe, in the exact wording that you would use, how
you would introduce yourself and describe what child life is
to a 10 year old patient who has never been hospitalized
before. The child’s diagnosis is still unknown.
8) References:
You must submit 2 letters of reference. Please do not use
friends or relatives.

9) Resume
Please submit one copy of your resume.
10) Interview:
An interview with the Child Life Director and/or the Child Life
staff is required. Upon receiving your completed application,
transcripts and letter of reference, you will be contacted for an
interview. A personal interview is preferred, however, a phone
interview may be arranged for out of state applicants.
11) Special Requirements:
Students ACCEPTED to the program must submit proof of the
following:
a) Occupational Health Exam (as per requirements of the
volunteer department)
b) Registration with hospital volunteer department
___________________
signature
____________________
date

Send completed application to:
Jennifer Grannis, CCLS
Morgan Stanley Children’s Hospital
Child Life Department
Tower 5, Room 561
3959 Broadway
New York, N.Y. 10032
Any questions please email jes9077@nyp.org