COMMON CHILD LIFE INTERNSHIP APPLICATION For Internship ...

COMMON CHILD LIFE INTERNSHIP APPLICATIONFor Internship Session:(Example: Fall 2012)Personal InformationLast Name First Name (M.I.)Present Phone Permanent Phone Email AddressPresent AddressPermanent AddressCity State/Province ZIP Code Country City State/Province ZIP Code CountryIn case of emergency, notify:Emergency ContactName Relationship AddressHome Phone Work Phone City State/Province ZIP Code CountryApplication CategoryIf University-affiliated:University-affiliated (internshiphours will count toward course credit)Independent (internship hours willNOT count toward course credit)[Please note: Some Child Life Internship ProgramsDO NOT ACCEPT independent interns]University Supervisor/Advisor Name Email Address PhoneUniversity NameUniversity Department AddressAcademic InformationPlease list ALL colleges and universities attended:*1.College/University NameCity, State/ProvinceTODates Attended ( mm/year) Graduation Date (mm/year)(include anticipated as well as official)MajorLevel: Bachelor’s Master’sCheck one of the above GPA Cum GPA in Major2.College/University NameCity, State/ProvinceTODates Attended ( mm/year) Graduation Date (mm/year)(include anticipated as well as official)Level: Bachelor’s Master’sCheck one of the above GPA Cum GPA in Major*NOTE: If additional space is necessary to complete the list of ALL colleges and universities attended, please go to page 7 of thisform.MajorPage 1

COMMON CHILD LIFE INTERNSHIP APPLICATIONFor Internship Session:(Example: Fall 2012)Application Checklist ReviewCompleted and Signed Application FormCollege/University Transcripts (if applicable, include both undergraduate and graduate)Reference Letters**Resume/Curriculum VitaeAttachment of additional application materials as required by each programI attest that the information in this application is true and accurate to the best of myknowledge.Signature:Date:REMINDER: Applicants must check with EACH internship program to verifythat internship eligibility requirements are met and to determine whetheradditional items are required to be submitted with this application form.Examples of additional requirements that MAY be required include, but are not limited to:• a completed background check form• completion of additional essay questions or exercises• official documentation of volunteer hours• **specific number and type of reference lettersSUBMITTING YOUR APPLICATION:Completed applications should be mailed directly to the internship programs towhich you are applying. DO NOT MAIL YOUR APPLICATION TO THE CHILDLIFE COUNCIL OFFICE. Please contact individual programs for their directmailing information.Page 6

COMMON CHILD LIFE INTERNSHIP APPLICATIONFor Internship Session:(Example: Fall 2012)For completion ONLY if additional space is required to complete applicant’s listing of Academic Information, Experience withChildren in Healthcare Settings, and/or Other Child-Related Experience.Please list remaining colleges and universities attended:Academic Information (Continued)3.College/University NameCity, State/ProvinceTODates Attended ( mm/year) Graduation Date (mm/year)(include anticipated as well as official)MajorLevel: Bachelor’s Master’sCheck one of the above GPA Cum GPA in Major4.College/University NameCity, State/ProvinceTODates Attended ( mm/year) Graduation Date (mm/year)(include anticipated as well as official)MajorLevel: Bachelor’s Master’s4.TOCheck one of the above GPA Cum GPA in MajorInstitutionSupervisor’s Name and CredentialsExperience with Children in Healthcare Settings (Continued)Position Title (e.g., volunteer, practicum student)May we contact?Supervisor’s TitleYes NoDates (mm/year to mm/year) Hours/ Week # of Weeks Total Hours Completed Supervisor’s PhoneBriefly describe population and responsibilities:5.TOInstitutionSupervisor’s Name and CredentialsPosition Title (e.g., volunteer, practicum student)May we contact?Supervisor’s TitleYes NoDates (mm/year to mm/year) Hours/ Week # of Weeks Total Hours Completed Supervisor’s PhoneBriefly describe population and responsibilities:Page 7

COMMON CHILD LIFE INTERNSHIP APPLICATIONFor Internship Session:(Example: Fall 2012)5.TOOrganization/EmployerSupervisor’s NameOther Child-Related Experiences (Continued)Position Title (e.g., nanny, teen counselor, teacher)May we contact?Supervisor’s TitleYes NoDates (mm/year to mm/year) Hours/ Week # of Weeks Total Hours Completed Supervisor’s PhoneBriefly describe population and responsibilities:6.TOOrganization/EmployerSupervisor’s NamePosition Title (e.g., nanny, teen counselor, teacher)May we contact?Supervisor’s TitleYes NoDates (mm/year to mm/year) Hours/ Week # of Weeks Total Hours Completed Supervisor’s PhoneBriefly describe population and responsibilities:Page 8