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AdventHealth for ChildrenChild Life DepartmentPracticum Application*Please note that we are only able to accept affiliated studentsName: _____________________________ Date: ______________________________University currently enrolled: ___________________________________________________________ACLP Required courses completed (must have 3 completed):Child Development____________________________________________________University contact information for affiliation agreementName: _____________________________________________________________________________Contact phone number: _______________________________________________________________Contact email address: ________________________________________________________________Applicant contact informationApplicant’s Phone number: ____________________________________________________________Applicant’s email address: _____________________________________________________________Emergency contact name and phone number: ______________________________________________Experience working with Children (Min. 50 hours in health care setting required)1. Institution/Placement: __________________________________________Position Title (volunteer, student): ______________________________ Ages: ____________Dates (mm/yr. - mm/yr.): ____________________ Total Hours Completed: ____________Briefly describe population, along with roles and responsibilities:2. Institution/Placement: ___________________________________________Position Title (volunteer, student): ______________________________ Ages: ____________Dates (mm/yr. - mm/yr.) _____________________ Total Hours Completed: ___________Briefly describe population, along with roles and responsibilities:3. Institution/Placement: ___________________________________________Position Title (volunteer, student): ______________________________ Ages: ____________Dates (mm/yr. - mm/yr.): ____________________ Total Hours Completed: ___________Briefly describe population, along with roles and responsibilities:ChecklistI wish to be considered for a Child Life Practicum position and have included the following required documentation:_____ Completed and Signed Application Form_____ Documentation of hours working with children (50-hour minimum in hospital setting) Must include verification from all experiences listed on resume._____ College Transcripts (Unofficial copies accepted. Official transcripts must be sent if accepted)*Student must have a minimum of 3 required ACLP courses completed when applying including 1 in Child Development._____ Reference Letters (2)_____ Resume_____ 1 page describing goals for your practicum experience and why you chose AdventHealth for Children_______________________________________________________________SignatureDateSubmit to: AdventHealth for ChildrenChild Life DepartmentNan Whitehead, CCLS601 E. Rollins StreetOrlando, Florida 32803*Students who complete their practicum at AdventHealth for Children are not eligible to complete their internship here. ................
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