Midwifery Practice Review Waitlist
Complete the form below to be added to the MPR Waitlist.
Contact Name:
*
First Name
Last Name
Phone Number:
*
Format: 0000 000 000.
Reason for waitlisting (eg. programs full, dates unsuitable). If dates are unsuitable, please provide an indication of your availability.
*
E-mail Address:
*
example@example.com
What is your context of practice?
*
Please Select
Hospital-based shift-work
Midwifery Group Practice
Privately Practicing Midwife
First Nations maternity service
Manager
Research
Policy
Other
Please comment below if you answered 'Other' or have multiple contexts of practice.
How long have you been a midwife?
*
0-2 years
3-5 years
6-10 years
11+ years
Are you an endorsed midwife?
*
Yes
No
Have you previously completed an MPR through ACM?
*
Yes
No
Please provide a brief description of your current and previous role / roles in midwifery (dot points welcome):
*
Are you a current ACM member?
*
Yes
No
Do you identify as First Nations Australian?
*
Please Select
Yes, Aboriginal
Yes, Torres Straight Islander
Yes, Aboriginal and Torres Straight Islander
No
Prefer not to say
Do you identify as Culturally and Linguistically Diverse (other than First Nations)?
*
Please Select
Yes
No
Prefer not to say
Optional - Please provide details to question above.
Where do you live? (state / territory)
*
Please Select
QLD
NSW
ACT
VIC
TAS
SA
WA
NT
Oher / Travelling Midwife
Where do you live? (MM category)
*
Please Select
MM1 Metropolitan areas
MM2 Regional centres
MM3-MM5 Rural towns
MM6-MM7 Remote communities
Submit Application
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