Coronavirus Update:What patients and families need to know

Child Life Services Shadow Program Application

Thank you for your interest in the Child Life Shadow Program! Please fill out the format least one month prior to the date you wish to shadow. If you have any questions, please contact Amy Ballin, MPH, CCLS .

Your Information

First Name:

Last Name:

Phone number

E-mail:

Address:

City:

State:

Zip:

Emergency contact name:

Emergency contact phone number:

18 or older:

Yes
No

Currently a student:

Yes
No

Are you currently pursuing a career in child life?

Yes
No

If not, please list your career aspirations

Please tell us a little bit about your reason for requesting this shadow opportunity and what you hope to gain from the experience:

If you need this shadow experience as part of a class requirement or for credit, please explain:

Please describe any previous hospital experience:

How did you find out about the Child Life Shadow Program at Children’s National:

Shadow opportunities are typically available Monday through Friday from 9:00 AM-12:30 PM or 12:30-4 PM. Please provide three specific date/time preferences.

Please type in what you see above: