American College of Nurse-Midwives Midwife of the Week Nomination Form
Section 1: Nominator Information
Nominator Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number (Optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Your Relationship to the Nominee(e.g., colleague, supervisor, patient, self-nomination encouraged, etc.)
*
Section 2: Nominee Information
Nominee Name
*
First Name
Last Name
Preferred Name (If different)
*
Title and Credentials
*
Organization/Practice Affiliation
Section 3: Bio and Recognition Details
Professional Bio (150–250 words)
*
Why are you nominating this midwife?
*
Anything else you’d like to add?
Section 4: Media Uploads
Upload Headshot
*
Browse Files
Drag and drop files here
Choose a file
High-resolution, professional or high-quality image preferred (JPG or PNG)
Cancel
of
Upload Additional Photos
Browse Files
Drag and drop files here
Choose a file
Action shots, community work, or images that represent their story (with permission)
Cancel
of
Section 5: Consent & Verification
Has the nominee consented to be nominated and to have their story shared publicly (e.g., social media, newsletters, website)?
*
Yes
No
If selected, do you give permission for ACNM to edit the bio for publication purposes?
*
Yes
No
Social Media Handles to tag and highlight the nominee.
Submit
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