Call for CLCC Leadership

Name

First NameLast Name

E-mail

example@example.com

Position(s) for consideration

Are you able to commit to the time required to serve?

If selected to serve, you would need to complete confidentiality and conflict of interest forms. Preview those forms here.

Are you able to sign these forms?

Do you have any conflicts of interest to disclose?

Where are you located?

Which state?

Which country?

How many years have you been certified?

Please list any credentials you hold in addition to your CCLS.

What best describes your highest degree?

What is your age range?

How do you identify?

Select the category that best reflects your background:

What is your job title?

Where do you work?

Name of hospital, university, or other employer

Which of the following best describes your role?

Which of the following best describes your current primary work setting:

Other

Are you working or have you worked in any of these roles?

Rows	Currently	Previously	Never
Adjunct professor
Internship supervisor
Internship coordinator

Which of the following best describes the community where you work?

Are you currently serving or have you previously served on a board or committee for CLCC, ACLP, or another child life organization?

Please list current roles and organizations

Please list previous roles and organizations

Why are you interested in serving on the Child Life Certification Commission?

What primary challenges and opportunities do you think the CLCC faces in the next few years?

What related skills or experiences do you have that would assist you in this role?

For example, please describe your skill set, approach, or experience in any/all of the following: Critical thinking and analysis; Strategic and/or operational planning; Communicating to facilitate group process; Experience and role supporting an organization’s mission; Integration of Diversity, Equity, and Inclusion into your practice and leadership; Management of a major project start to finish; Leadership philosophy and practice; Fiscal responsibility and management

What unique experiences and/or perspective would you bring to service on the commission?

Is there anything else you want the nominating committee to know?

If you aren't selected for a role on the commission, can we reach out to you about opportunities to serve on other CLCC committees?

Child Life Certification Commission Leadership Application