Birthmatters Midwifery! Services - Apprenticeship Form

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Apprenticeship Form

Your Details

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Email:*

Daytime Phone:

Evening Phone:

General Information

Birth Date:

Marital Status:

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 (Include initials.)

Initial prenatal visits

Postpartum visits

Newborn exams

Why did you decide to become a midwife?

What is your current educational status in midwifery?

Do you have a transcript?

Yes

What are your midwifery educational goals?

Please list your midwifery-related experience.

What are your long-term midwifery plans?

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

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. (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.)

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

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

By clicking the send button below, you 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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Thank you!

Your Apprenticeship Form was successfully validated and ready to be sent.

After I've read through your application I will call you for an interview.

If you have any questions, please call 719-660-2743.

Kind Regards,

Dotti

Phone: 719-598-6509 • Fax: 719-533-0919 • Cell: 719-660-2743 • Office: 2211 N. Weber St., Colorado Springs, CO, 80907
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