Application for A Wombman's Way Warrior Midwife Training Program

Application for A Wombman's Way Warrior Midwife Training Program

Please fill out the application form carefully
Personal Information
Full Name

First Name Last Name
Birth Date

Month Day Year
E-mail
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Education Background

List any of your previous Midwifery schools, beginning with the most recent

1st School Information
School name
GPA
Graduated

Yes No
Entry date

Month Day Year
Date
Graduation date

Month Day Year
Date
Exit date

Month Day Year
Date

Form collapse ender
Activity Information
Are you a high school graduate? Also, have you attended or are attending any Post-secondary Schools? List below
What Birth related websites, magazines, journals do you regularly read?
If you have attended nursing school or are planning to attend, are you or will you become a CNM?
Are you currently a practicing traditional, lay or direct-entry midwife?
Are you currently an apprentice?
Do you plan to pursue your CPM credential?
Do you plan on becoming Licensed or Certified to practice midwifery in your state? Which state do you plan to practice in?
Are you a Doula? If so, did you certify with an organization?
Is midwifery legal in the state in which you intend to practice?
What are your state's licensing requirements, if any? (Please review your state laws regarding midwifery education).
Approximate number of midwives in your local area? What are their names and do you know any of them?
Is midwifery and homebirth well supported by the greater community in your area? (For example, are there supportive doctors, childbirth educators, allied health professionals, etc?)
Are you part of your profession's organization as a doula or other birth-worker organization?
Do you know any AWWWMT enrollees?
Please initial below that you have read and acknowledge information below. A Wombman's Way Warrior Midwife Training reserves the right to accept or reject any applicant. A telephone interview will be required prior to approval
All curriculum materials received during enrollment are the intellectual property of AWWWMT and are not allowed to be copied or shared in any way
AWWWMT reserves the right to accept or reject any submitted work. Students will have the opportunity to re-submit work until it is accepted.
I realize that there will be additional expenses not included in my enrollment. This includes, but is not limited to books, photocopying, postage, conference recordings, videos, and supplies.
I understand that this course is intended as preparation for, or complement to, practical experience under a supervising midwife. I will not, under any circumstance, misrepresent myself as a qualified birth attendant based on enrollment in, or completion of, this course alone. I am in complete agreement that my education will not be complete without an apprenticeship and/or other forms of practical experience. AWWWMT may be able to provide assistance in locating a preceptor but cannot make that guarantee.I will not represent myself as an AWWWMT graduate until I have the certificate in my possession
I understand that this course demands a great deal of time and study. What I learn depends on how much effort I invest.
I understand that my enrollment period is limited and I will be assigned a PCD (Projected Completion Date) that is 48 months from my start date. I understand that my enrollment fee is for access to the program regardless of whether or not I choose to complete the program. While tuition is non-refundable I understand that sabbaticals may be requested and are granted only at the discretion of the director
I HAVE READ AND UNDERSTAND THE ENROLLMENT AGREEMENT AND AGREE TO THE TERMS AND CONDITIONS PRESENTED HEREIN. Please sign & date
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Application for A Wombman's Way Warrior Midwife Training Program

Personal Information

Education Background

Activity Information