Form A: Coursework Completion Verification
Name: Major:
The following courses must be successfully completed prior to enrolling. Please list the courses you have completed and
identify those that you plan to finish in the near future. Please fill out entire form completely.
INSTRUCTIONS FOR COMPLETING THIS FORM
*This form is a fillable PDF form. It must be opened and completed using Adobe Reader. This free software may be
downloaded from the Adobe website.
*Please provide all of the information requested on this form.
*You may save your partially or totally completed Form A to your computer by clicking on File > Save As and entering a
name for the file in the Save As dialog box. This saved version may be reopened at a later date and worked on again.
*When your form is ready, click on Print to print the copy that will be signed and submitted.
English Composition/Writing Intensive Course
Course Number Course Title
Course Description
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Human Development Across the Lifespan
Course Number Course Title
Course Description
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Infant/Child Development
Course Number Course Title
Course Description
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Adolescent Development
Course Number Course Title
Course Description
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Biological Science
Course Number Course Title
Course Description
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Research Methods
Course Number Course Title
Course Description
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Form A: Coursework Completion Verification Name:
Additional Upper Level Courses
May be from the following content areas: Psychology, Sociology, Death & Dying, Expressive Therapies, or any field related to Child Life.
Example Courses: Family Dynamics, Family Theories, Hospitalized Child and Family, Abnormal Psychology
Please fill out entire form completely.
Focus Area
Course Number Course Title
Course Description
Explanation of How
Course Relates to
Child Life
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Focus Area
Course Number Course Title
Course Description
Explanation of How
Course Relates to
Child Life
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Focus Area
Course Number Course Title
Course Description
Explanation of How
Course Relates to
Child Life
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Focus Area
Course Number Course Title
Institution
Course Description
Explanation of How
Course Relates to
Child Life
Semester Completed
or Future Plan of
Completion
Grade Earned
The following information is NOT required for admission
Please see the next page for CLC requirements and course description.
For Towson University Department records, please complete the following form:
Have you completed
a Child Life course
meeting the CLC
guidelines?
Course Number Course Title
Course Description
Institution
Semester Completed
or Future Plan of
Completion
Grade Earned
Do you have a
completed CLC
Course Verification
Form?
For questions about the CLC Course Verification Form, please see:
Child Life Course Verification Form
Definition of Child Life Course
All applicants for the fall 2013 and subsequent exam administrations will be required to have successfully completed a
minimum of one child life course taught by a Certified Child Life Specialist as part of the 10-course requirement. The
Child Life Certifying Committee (CLCC) has defined what this course must include in order to satisfy the requirement.
The required child life course must have a focus on children in the health care environment and must be taught by a
Certified Child Life Specialist (CCLS). ALL of the following applied areas of study must be included in the course.
1. Child Life Documents-This will provide knowledge and understanding of the Official Documents of the Child Life
Council (CLC) including the Code of Ethical Responsibility, Child Life Competencies, and Standards of Clinical Practice,
the Child Life Mission, Values and Vision Statements, and the Code of Professional Practice.
2. Scope of practice – This will provide an introduction to the spectrum of child life practice in direct and non-direct
services in pediatric health care including a historical review of the profession and its development in the evolution
of children’s health care.
3. Impact of illness, injury and health care on patients and families – This will illustrate, within the context of
developmental theory, the stressors and developmental and psychosocial treatment issues that affect the health
care experience of a “child and family” including siblings.
4. Family-Centered Care- This will provide an understanding of the key principles of patient- and family-centered care,
including principles of respect and dignity, information sharing, supporting participation in care, and collaboration in
relationship to child life practice.
5. Therapeutic play- This will provide students with opportunities to examine elements of play, benefits of play, and
various therapeutic play modalities for the clinical setting.
6. Preparation- This will include both historical and current perspectives on the rationale for, and techniques and
outcomes of preparation, as well as accepted preparation methods for health care encounters and life-changing
events.
Child Life Course Documentation
The CCLS Instructor is expected to complete the Child Life Course Verification form and provide a signed form to each student upon successful
completion of the course. It is incumbent upon the instructor to use the form to identify the topics covered in the course. It is the student's
responsibility to save all necessary verification forms that demonstrate coverage of the six areas of applied study. Without this documentation,
the requirement will not be considered satisfied.
(Child Life Council, 2013)