Please type your application and submit by February 1 to the Child Life Specialist Program,
Polsky Room 181 or by email to rresler@uakron.edu
Name
(Mrs., Miss, Ms., Mr.)
Present Address
Permanent Address
Telephone ( )
( ) Present address
E-mail____________________________________
To what address should application correspondence be sent?
( ) Permanent Address
High School City/State Dates Attended Major
College/University (List all attended) City/State Dates Attended Major
College Honors and Awards
Recommendations: List the names of all individuals who will complete your recommendation forms.
(Required 3) Need to be professional – college instructor/professor, employer or volunteer coordinator)
Name Title Address Phone

Extracurricular/Volunteer Activities: List memberships (specify year(s) of membership), appointed or elected offices you held in organizations. Volunteer activities not related to child life/child development.
Paid work experience in the past 3 years (you may include work experience in the past 5 years if applicable to your situation): List paid work experience beginning with the most recent experience.
Do not list experiences that were part of required course/practicum/field experience. Briefly describe responsibilities. (We reserve the right to contact references and work supervisors)
Organization Name
City/State
Position/
Title
Inclusive Dates
(Mo./Yr.)
Hr./Wk Name and Title of Supervisor/
Phone #
1.
Key Responsibilities
2.
Key Responsibilities
3.
Key Responsibilities
Use additional pages as needed.
Volunteer Experience related to child development in the past three years (camps, schools, health fairs, church): List volunteer experience related to child development, beginning with most recent experience. Do not include observations/experiences with children that are required for a course.
Students need a minimum of 50 hours experience with children. It can be paid experience.
Organization Name
City/State
Position/
Title
Inclusive Dates
(Mo./Yr.)
Hr./Wk Name and Title of Supervisor/
Phone #
1.
Key Responsibilities

2.
Key Responsibilities
3.
Key Responsibilities
Use additional pages as needed.
Instructions for completion of course work section of application:
1. List all course work completed under each category on the following pages. For each category identify those courses completed as part of the Child Life Program requirements followed by additional courses that may have been completed in that category.
2. List courses in reverse chronological order (most recent to oldest).
Child Life/Child Development Courses : (Include all courses in child life/child development). Use additional pages as needed. Identify with a (X) if courses included a clinical component.
College or
University
Course
Title
Lab/
Clinical
Course
No.
Term
& Year
No. of
Credits
Grade
Earned
Physical, Biological Sciences, Mathematics: (Include chemistry, anatomy, physiology, mathematics, statistics, medical terminology, etc.)
College or Course Course Term & No. of Grade
University Title No. Year Credits Earned

Behavioral and Social Sciences: (include all courses such as sociology, psychology, anthropology, counseling, ethics, etc.)
College or
University
Course
Title
Course
No.
Term &
Year
No. of
Credits
Grade
Earned
Communication Courses: (Include all courses in writing, English composition, speech, foreign language, etc.)
College or
University
Course
Title
Course
No.
Term &
Year
No. of
Credits
Grade
Earned
Undergraduate Course work:
Cumulative grade point average based on 4.0 system: __________
Graduate Course Work:
Cumulative grade point average based on 4.0 system: ___________
SAT or ACT Score: Date taken:
GRE Score:
(If applicable)
Date taken:
Month/year
Written
month/year
Quantitative: Analytical:
I certify that the information that I have provided in this application is true and accurate and recognize that any false or incorrect statements made herein will be grounds for my dismissal from the program.
Date
Signature
Please respond to each of the following statements: Please type your answers.
1. Why are you interested in pursuing a degree in child life? (Approximately 200 words)
2. Describe the ways child life contributes to the health care experience of a child and family. (Approximately 200 words)
3 .
Describe a situation that was difficult for you and how you coped with it. It can be school related or personal. (Approximately 200 words)
4. Provide a specific example of a time that you used play to meet the developmental needs of a child. (Approximately 200 words)

(X) Check:
( ) 1. I will successfully complete all of the first two-year course requirements prior to the academic year in which admission to CL is requested.
( ) 2. I have included a transcript of all my grades and my GPA is at least 3.0 on a 4.0 scale.
( ) 3. I have completed the following courses: Anatomy and Physiology ( ), Medical Terminology ( ),
C hild Development ( ), and Direct Experience 7700:295
( ) 4. If an international student, I have provided a TOEFL, or Michigan Test Score as an objective measure of English as a foreign language.
( ) 5. On a separate sheet, I have included a list of the prerequisite courses in which I am currently enrolled and/or will take during the summer sessions.
( ) 6. I have attached a photocopy of my ACT or SAT Scores. (These are often included on high school transcripts or sometimes on your University of Akron Application for Admission). If I am a post baccalaureate or graduate student, I have attached a copy of my graduate transcript.
( ) 7. I am willing to assume the expense of Health Insurance (if not already covered) and will have verification by the beginning of the fall term. (Applications provided when accepted into the program).
( ) 8. I am willing to assume the expense of transportation costs to and from the clinical sites and any other incidental expenses associated with the program.
( ) 9. I am willing to take the prescribed medical examination required by affiliated agencies. (Forms provided upon acceptance into the program).
( ) 10. Do you have any extenuating circumstances (physical conditions, etc.) that should be considered?
( ) yes ( ) no. If yes, please submit a separate sheet describing.
( ) 11. If I am a transfer student from another institution or from another college within The University of
Akron, I have applied to The College of Health Professions and have included The University College
Evaluation of my courses. (Transfer students should allow at least six weeks to receive evaluations).
( ) 12. I have included a minimum of three professional letters of recommendation; at least one from an employer, one from an instructor and one from someone who has observed me interact with children.
( ) 13. I am able to verify that I have at least 50 hours of experience with children outside of course requirements/observations.
Signature:
Date:

Pg.1 Reference
CHILD LIFE SPECIALIST TRAINING PROGRAM
RETURN BY MAIL TO:
Director, Child Life Program College of Health Professions
181 Polsky The University of Akron Akron, Ohio 44325-3001
(330) 972-8040
Name of person providing reference:
Position and Title:
Address:
City, State, Zip Code: Telephone: ( )
Professional/Relationship to applicant:
How long have you know the applicant?
Please respond as honestly as possible to the following characterizations as descriptors of the applicant’s behavior.
Motivation
( ) Usually purposeless
( ) Vacillating
( ) Usually purposeful
( ) Effectively motivated
( ) Highly motivated
Industry
( ) Seldom works, even with reminders
( ) Requires reminders
( ) Completes tasks with minimal reminders
( ) Completes tasks
( ) Seeks additional work
Initiative
( ) Merely conforms
( ) Seldom initiates
( ) Frequently initiates
( ) Consistently self-reliant
( ) Actively creative
Integrity
( ) Unreliable
( ) Questionable at times
( ) Generally honest
( ) Reliable, dependable
( ) Consistently trustworthy
Influence and Leadership
( ) Negative
( ) Cooperative
( ) Participates in minor affairs
( ) Contributes in important affairs
( ) Respected by peers as effective leader
Concern for Others
( ) Uncaring, indifferent
( ) Self-centered, self-involved
( ) Somewhat socially concerned
( ) Generally concerned
( ) Deeply and actively concerned
Responsibility
( ) Not dependable
( ) Moderately dependable
( ) Mostly dependable
( ) Conscientious
( ) Assumes responsibility often
Emotional Stability
( ) Unresponsive
( ) Excitable
( ) Usually well-balanced
( ) Well-balanced
( ) Exceptionally stable

CHILD LIFE SPECIALIST TRAINING PROGRAM REFERENCE:
PAGE 2
A Child Life Specialist is a person who has been trained to work in a hospital setting with mildly and/or terminally, ill/hospitalized, children and their families. Their function is to help children cope with preparation for medical procedures and the effects of hospitalization, often through the use of play. As a member of the health care team (including, physicians, nurses, and social workers), how well could this candidate, in your opinion, handle the tasks described above?
In reference to the applicant’s aspirations for a career in Child Life, include a personal statement of your opinion as it relates to the applicant and the applicant’s career in Child Life.
Signature: Date:
Thank you for your cooperation. We appreciate your willingness to assist us in evaluating the student.

The University of Akron
Child Life Specialist Program
Volunteer & Work Experience Verification Form
Student Name _______________________________________________________________
Circle One: Fall Spring Summer
Permanent Address __________________________________________________________
City_________________________________ State _____________ Zip Code _____________
Email _____________________________________ Phone __________________________
Year of Graduation _____________________________
I hereby certify that the above named child life student has successfully completed a Volunteer or work experience rotation in:
Circle One: Community Health Care
Please provide a brief description of the st udent’s activities during this experience:
The Volunteer or work experience reported on this form took place at the following site:
Name of Site _______________________________________________________________
Name of Contact Person _____________________________________________________
Street Address, City, State, Zip Code ____________________________________________
Email _____________________________________________________________________
Area Code/Phone Number_____________________________________________________
Date____________________________ Number of Hours_____________________
Month Day Year
Signature of Contact Person ___________________________________ Date _____________