The Arise BIPOC Midwife Student Application

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address for your Intake Package

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Current Educational Institution or N/A

Genre of Midwifery (Traditional, CPM, CM, CNM)

Please describe where you are in your midwifery journey

Personal Bio, which will be displayed on the Arise BIPOC Midwife list of Honorees

What are your various social media contacts? (ie. Instagram, Facebook, Twitter, Websites, etc). Is it okay to tag you on public posts? or N/A

Upload your Headshot or email to info@ariseblackmidwife.org

This event on October 17, 2026 2-6pm will be hybrid, and both virtual and in-person participants will enjoy the same benefits. Will you be participating in the Pinning Ceremony in person or virtually?

If you are unsure about attending in person, please explain.

Honorees will be required to participate in preparation activities the day before the affair on Friday, October 16th, 5-8 pm. Are you available to participate?

What size shirt do you wear?

PLEASE SELECT YOUR PERSONAL TITLE/TENANT/JOURNEY PHRASE. For Example, let's say Rising Midwife Jackie chose the word "Serenity" for their Title. The word "Serenity" will be used to describe Jackie during the Ceremony, followed by the definition [i.e. Serenity: A Title for Queens! The state of being calm, peaceful, and untroubled.]One's Title should be significant to them and can be in any language! Please provide the word, the language, the meaning & the pronunciation for the Guiding Midwife Announcer!

Please list the names of your midwifery preceptors/mentors and share if you plan to invite them and whether you desire them to participate in the ceremony. You will be responsible for inviting them and informing them of your desire for their participation. Non-BIPOC supporting guests are welcome. Please guide all your guests to the Eventbrite to obtain their tickets. Space is limited: https://www.eventbrite.com/e/the-arise-bipoc-midwife-future-of-midwifery-celebration-registration-1993163721345?aff=oddtdtcreator&keep_tld=true

In-person attendees can invite up to 2 family/friends. How many family/friend tickets do you plan to use?

"ARISE Community" is an opportunity for your village to support you by giving a tax-deductible donation in your honor using the Pledge platform: https://www.pledge.to/arise-bipoc-midwife . Some may choose to give a donation to be present (a suggested donation of $25) or donate towards your regalia (a $99 donation). If multiple individuals donate towards your regalia, the funds will be remitted back to the Honoree in support of their midwifery education. Please let us know if you would like to participate in the ARISE Community effort and share feedback on whether this could be an effective way to support you.