Dell Children’s Medical Center of Central Texas
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Child Life Internship Reference Form

Please complete the information below. The reference is for a child life intern position at Dell Children’s Medical Center. The internship is a 15 week clinical experience designed as the final step in the process to obtain certification as a child life specialist. The internship is designed to train individuals to work with children and families in healthcare settings and to promote effective coping through play, preparation, education, and self-expression activities. This submission will be routed to the Dell Children’s Child Life Education Committee and not sent to the applicant.

Fields outlined in orange are required


I am submitting a reference for:
My Name:
My Institution/Organization:
Phone number:
May we contact you for further information?
  Yes    No
How long have you known applicant?
In what context?
Child Life Practicum Supervisor
Child Life Volunteer Supervisor
Employer / Supervisor / Manager / Director
School Advisor
Other (specify) 

Please check the rating that is most applicable.

  Excellent Above Average Average Below Average Poor Do Not Know
Child Development Knowledge
Compassion and Concern for Others
Interactions with Children
Interactions with Families
Problem Solving
Communication Skills
Critical Thinking
Ability to take direction and feedback
Motivation to Learn
Rapport Building Skill


What qualities does the applicant have that would contribute to his or her success as a child life intern?

Would you recommend this applicant as a child life intern?

Yes, highly

Yes, somewhat

No, would not recommend

If somewhat or no, please state concerns:

Other Comments:

Please click to submit this form to the Dell Children’s Child Life Education Committee.