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Child Life DepartmentPracticum ApplicationName: _____________________________ Date: ______________________________Home Address: ______________________Mailing Address: _________________________________________________________________________________________________________________________________________________________________Home/Cell Phone: ____________________E-mail Address: _______________________Emergency Contact:Emergency Contact:Name: ______________________________Name: _____________________________Phone: _____________________________Phone: _____________________________Address: ___________________________Address: ____________________________Email: _____________________________Email: _____________________________If University Affiliated, please fill out the following:University/College: ___________________Supervisor/Professor: _______________________Major: ____________________________Minor: _____________________________Level (please check one): Undergraduate: _____Graduate: ______ If Independent from a college/university, please list all colleges and universities attended:College/University: _____________________City, State/Province: __________________Dates Attended (mm/yyyy): __________________Graduation Date: _____________________Experience working with Children (Min. 50 hours in health care setting required)1. Institution/Placement: __________________________________________Position Title (volunteer, student): ______________________________ Ages: ____________Dates (mm/yyyy - mm/yyyy): ____________________ Total Hours Completed: ____________Briefly describe population, along with roles and responsibilities:2. Institution/Placement: ___________________________________________Position Title (volunteer, student): ______________________________ Ages: ____________Dates (mm/yyyy - mm/yyyy) _____________________ Total Hours Completed: ___________Briefly describe population, along with roles and responsibilities:3. Institution/Placement: ___________________________________________Position Title (volunteer, student): ______________________________ Ages: ____________Dates (mm/yyyy - mm/yyyy): ____________________ 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 health care setting)_____ College Transcripts (Unofficial copies accepted. Official transcripts must be sent if accepted) *Student must be a minimum of a junior in college to meet eligibility for practicum. _____ Reference Letters (2)_____ Resume and Letter of Intent_______________________________________________________________SignatureDateSubmit to: Florida Hospital for ChildrenChild Life DepartmentDebbie Spencer, CCLS III601 E. Rollins StreetOrlando, Florida 32803*Students who complete their practicum at Florida Hospital for Children are not eligible to complete their internship here. ................
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