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Practicum Questionnaire
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10
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1
Name
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First Name
Last Name
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2
Address
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Street Address
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City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
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Aruba
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Azerbaijan
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Bangladesh
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Belgium
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Benin
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Brunei
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Cote d'Ivoire
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Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
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El Salvador
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Estonia
Ethiopia
Falkland Islands
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Fiji
Finland
France
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The Gambia
Georgia
Germany
Ghana
Gibraltar
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India
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Iran
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Israel
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Jamaica
Japan
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Jordan
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Laos
Latvia
Lebanon
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Liberia
Libya
Liechtenstein
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Luxembourg
Macau
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Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Email
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example@example.com
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4
Which semester are you applying for?
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Summer
Fall
Spring
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5
Have you applied before?
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YES
NO
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6
In 50 words or less, utilizing child life language, what is child life?
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7
In 200 words or less, why are you interested in pursuing this pre-internship experience at Denver Health?
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8
Are you prepared to answer the following questions?
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1. In 50 words or less what is Child Life? 2. In 200 words or less, why are you interested in pursuing this career? 3. Please list your top 3 strengths and why? 4. In 250 words or less, Tell us about a time you have been flexible? 5. In 250 words or less, tell us about a meaningful interaction you had with a child and family. 6. Please list 3 goals and objectives for this practicum? 7. What professional experiences do you have working with children, please fill out chart below? 8. Check the time-slots for when you are available. 9. Please upload your current resume, cover letter, transcripts and two letters of recommendation.
Yes
No, I'll come back when I'm ready
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9
What is Child Life?
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50 word limit
0/50
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10
Why are you interested in pursuing this career?
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200 word limit
0/200
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11
Please list your top three strengths and why?
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12
Tell us about a time you have been flexible?
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250 word limit
0/250
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13
Tell us about a meaningful interaction you had with a child and family.
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250 word limit
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14
Please list 3 goals and objectives for this practicum?
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15
Please provide a pre-internship goal with 2 objectives each for the following topics: 1) Multi-disciplinary team player, 2)Advocacy, 3) Rapport building, and 4) Developmental theory
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16
What professional experiences do you have working with children, please fill out chart below?
Institute Name (e.g. Denver Health)
Type of Facility
Dates / Total Hours
Position Title
Ages
Type of Population
Brief Description of Your Responsibilities
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
1
2
3
4
5
Institute Name (e.g. Denver Health)
Row 0, Column 0
Type of Facility
Row 0, Column 1
Dates / Total Hours
Row 0, Column 2
Position Title
Row 0, Column 3
Ages
Row 0, Column 4
Type of Population
Row 0, Column 5
Brief Description of Your Responsibilities
Row 0, Column 6
Institute Name (e.g. Denver Health)
Row 1, Column 0
Type of Facility
Row 1, Column 1
Dates / Total Hours
Row 1, Column 2
Position Title
Row 1, Column 3
Ages
Row 1, Column 4
Type of Population
Row 1, Column 5
Brief Description of Your Responsibilities
Row 1, Column 6
Institute Name (e.g. Denver Health)
Row 2, Column 0
Type of Facility
Row 2, Column 1
Dates / Total Hours
Row 2, Column 2
Position Title
Row 2, Column 3
Ages
Row 2, Column 4
Type of Population
Row 2, Column 5
Brief Description of Your Responsibilities
Row 2, Column 6
Institute Name (e.g. Denver Health)
Row 3, Column 0
Type of Facility
Row 3, Column 1
Dates / Total Hours
Row 3, Column 2
Position Title
Row 3, Column 3
Ages
Row 3, Column 4
Type of Population
Row 3, Column 5
Brief Description of Your Responsibilities
Row 3, Column 6
Institute Name (e.g. Denver Health)
Row 4, Column 0
Type of Facility
Row 4, Column 1
Dates / Total Hours
Row 4, Column 2
Position Title
Row 4, Column 3
Ages
Row 4, Column 4
Type of Population
Row 4, Column 5
Brief Description of Your Responsibilities
Row 4, Column 6
Institute Name (e.g. Denver Health)
Row 5, Column 0
Type of Facility
Row 5, Column 1
Dates / Total Hours
Row 5, Column 2
Position Title
Row 5, Column 3
Ages
Row 5, Column 4
Type of Population
Row 5, Column 5
Brief Description of Your Responsibilities
Row 5, Column 6
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17
Check the time-slots for when you are available.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
All Day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Morning
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
Afternoon
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Row 2, Column 7
Evening
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Row 3, Column 7
All Day
Morning
Afternoon
Evening
Sunday
Row 0, Column 0
Monday
Row 0, Column 1
Tuesday
Row 0, Column 2
Wednesday
Row 0, Column 3
Thursday
Row 0, Column 4
Friday
Row 0, Column 5
Saturday
Row 0, Column 6
Row 0, Column 7
Sunday
Row 1, Column 0
Monday
Row 1, Column 1
Tuesday
Row 1, Column 2
Wednesday
Row 1, Column 3
Thursday
Row 1, Column 4
Friday
Row 1, Column 5
Saturday
Row 1, Column 6
Row 1, Column 7
Sunday
Row 2, Column 0
Monday
Row 2, Column 1
Tuesday
Row 2, Column 2
Wednesday
Row 2, Column 3
Thursday
Row 2, Column 4
Friday
Row 2, Column 5
Saturday
Row 2, Column 6
Row 2, Column 7
Sunday
Row 3, Column 0
Monday
Row 3, Column 1
Tuesday
Row 3, Column 2
Wednesday
Row 3, Column 3
Thursday
Row 3, Column 4
Friday
Row 3, Column 5
Saturday
Row 3, Column 6
Row 3, Column 7
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of 4
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18
Please upload a current resume and two letters of recommendations; one familiar with your work with children/families.
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