Child Life Internship Application

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Child Life Internship Application
You must print this page and submit it with your completed application packet.
Date:
Name:
University:
Year In School:
Anticipation Graduation Date:
Major:
Minor:
When do you plan to participate in an internship:
How many weeks are in your semester:
From:	To:
When are your scheduled University breaks and/or holidays:
Do you wish to work through your breaks and/or holidays:
University Supervisor:
Address:
Telephone:
Fax:
E-Mail:
Best time to Contact:
Applicant's University (or present) address:
Home address:
University phone number:
University e-mail:
Home phone number:
Home e-mail:
In Case of Emergency, notify:
Name:
Address:
Telephone:
Relationship:
Optional Information:
Sex:
Marital Status:
Nationality:
Name of Spouse:
Spouse's Occupation:

I understand that if accepted, I must attend all required Clarian Health orientations and complete the Volunteer Services health screen. I have read the attached Internship Packet and understand the requirements. I have included all of the application information.
Student's Signature	_____________________________________
Date	_____________________________________

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