Birth Matters Apprenticeship Application Form


	Contact Details

*First Name:

*Last Name:

*Street Address:

*City:

*State:

*Zip Code:

-

*Email:

Daytime Phone:

- - x

Evening Phone:

- - x


	General Information

Birth Date:

/ /

Marital Status:

Or:

No. of Children:

No. of Pets:


	Midwifery Information

Number of each of the following you've experienced

Births:

Include your own children, hospital observes, catches, etc.

Catches:

Primaries:

Prenatals:

Postpartum Visits:

Newborn Exams:

Why did you decide to become a midwife?

(chars left: 200)

What is your current educational status in midwifery?

(chars left: 200)

*Do you have a transcript?

Yes

No

What are your midwifery educational goals?

(chars left: 200)

Please list your midwifery-related experience:

(chars left: 200)

What are your long-term midwifery plans?

(chars left: 200)

What other (non-midwifery) education do you have?

(chars left: 200)

Application requirements for which you'd like an exception:

Be enrolled as a student of the National College of Midwifery (NCM) or an equivalent school

Be actively taking classes and pursuing a midwifery certificate or degree *

Be available to attend births

Have reliable transportation

Have reliable babysitting

Have a pager or cell phone

Live close enough to Colorado Springs to arrive in a reasonable time to births

Other:

* Of course you can decline births for special occasions, illness, vacations, and the like. But you do need to be available most of the time.

If you requested any of the above exceptions, please explain:

(chars left: 500)

*Agreement:

By clicking the send button below, I agree to the following:I hereby apply for apprenticeship with Birth Matters! Midwifery Services. I certify that I have answered all questions on this application truthfully and have given an honest representation of my education and experience.I understand that if accepted as an apprentice I am required to keep all information about clients, the midwives, and the practice of Birth Matters! Midwifery Services confidential, and that this confidentiality duty extends forever and in all circumstances, even after the termination of the apprenticeship, whether voluntary or involuntary. I hereby commit to keep confidential all information described above.

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