IRM Initial Application and Registration

IRM Initial Application & Registration Form

This form is to be completed as the first step in registering as a student or applicant for all IRM credentialing programs. This includes all CIM board exam pathways, CTBA and CGD.
Name*

First NameMiddle NameLast/Surname
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province & Country

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
WhatsApp Number
Highest Level of Education Completed, Name of School and Date of Completion *
National ID Number, Passport Number or Driver’s License Number *
Home Country of Permanent Residence *
Board Exam you will sit for upon completion of requirements *
Are you currently enrolled in a Midwifery, Doula or Birth Attendant training program? If yes, please provide the name and your progress in the program.*
Do you currently have a Clinical Preceptor? If yes, please provide their name and email address.*
Have you ever been arrested or convicted of a crime, other than a traffic violation? If yes, please give a brief description with the date of offense and the legal outcome. If yes, IRM may contact you for more information. Not all criminal history is grounds for automatic ban from our credentialing programs. Bans from IRM are decided on a case by case basis, due to the nature and severity of the crime, the circumstances surrounding it and proof of rehabilitation. *
Do you agree with the IRM Mission Statement?Mission Statement: IRM is a global nonprofit organization dedicated to credentialing highly skilled, autonomous Maternity care providers. Applicants agree to use their skills for the betterment of global Maternal Child Health. You agree to support a Woman’s: Right to life, Right to health, Right to privacy, Right to equal treatment, Right to informed consent and childbirth education, Right to refuse medical intervention while in labor/birth, Right to choose her birth partner and team, Right to choose her birthing place/position and her Right to dignified, respectful care. You are agree to provide care that is free from discrimination and coercion, throughout pregnancy and childbirth, as protected in international and regional human rights law and standards.*

Yes I agree with the complete IRM Mission StatementNo I do not agree with the complete IRM Mission Statement
With my signature I state that the information I provided in this document is true to the best of my knowledge. I understand that false information provided is grounds for dismissal and will result in a permanent ban from all IRM credentialing programs. *

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Date*

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IRM Initial Application & Registration Form