New York Midwives Abortion Trainee Application

  • New York Midwives Abortion Trainee Application

  • Section 1: Applicant Information

  • Format: (000) 000-0000.
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  • Section 2: Didactic Training

  • Have you completed an approved didactic abortion training?
  • Which program did you complete?
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  • 1. Have you attended an in-person SIM workshop?

  • Section 3: Clinical Readiness & Interest

  • Which clinical competencies are you hoping to gain or strengthen?
  • Have you completed any of the following trainings?
  • Are you comfortable working in clinical environments that provide full-spectrum abortion care?

  • Section 4: Availability & Logistics

  • Preferred Start Date or General Availability for 2025-2026
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  • Are you able to travel outside your area for the preceptorship?

  • Section 5: References

  • Please list three professional references who can speak to your clinical experience, reliability, professionalism, and suitability for abortion care training.

    If possible, at least one reference should be a clinical supervisor or educator.

  • Reference #1

  • Reference #2

  • Reference #3

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  • Section 6: Demographic Information (OPTIONAL)

  • The following questions are optional and will only be used for internal purposes to help NYM better understand and support the diversity of our applicant pool. Your responses will not affect your eligibility or application review.

  • Race/Ethnicity (Check all that apply)
  • Gender Identity
  • Do you identify as LGBTQIA+?
  • Do you consider yourself from an underrepresented or historically excluded background in medicine or midwifery?

  • Section 7: Signature & Attestation

  • I, the undersigned, hereby attest that all the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation or omission may disqualify me from participation in the New York Midwives Abortion Trainee application or result in termination from the program.

    I acknowledge that submission of this application does not guarantee placement or participation. I authorize NYM or its designated representatives to contact the references provided and verify any information contained herein. I understand that acceptance into the program may be contingent upon background checks, credential verification, and availability of a suitable preceptor match. Please note: vaccination requirements vary by clinical site; COVID-19 vaccination may be required.

    I further agree to uphold all applicable laws, professional ethical standards, and clinical safety protocols throughout the duration of the preceptorship. I consent to follow NYM’s policies and procedures and understand that I may be required to sign additional agreements prior to placement.

    By signing below, I confirm my voluntary participation and acknowledge that I have read, understood, and agree to the terms stated above.

  • Date Signed
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