Student Apprentice Program Application

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Please fill out this form COMPLETELY to be considered for the Birthing Your Way Student Midwife program.

Name *

Address *

Phone Number *

Best email *

Preferred Start Date *

YYYY

Preferred End Date *

YYYY

If accepted into our program, do you plan to reside at the birth center during your stay? *

Yes

No, I will provide my own housing

I'm not sure, I need more information

Your experience with birth. Please be as specific as possible. *

How many births have you attended as a student midwife? *

How many prenatal visits have you attended as a student midwife? *

How many postpartum visits have you attended as a student midwife? *

How many newborn exams have you attended as a midwife? *

Please list any current and/or past apprenticeships. *

What is your current educational status in midwifery? *

What books specific to midwifery have you read? What have you learned from them? *

Do you have any medical training? *

Yes

If yes, please briefly explain.

Briefly describe your breastfeeding education/training. *

Why did you decide to become a midwife? *

What is your birth philosophy? *

What is your diet/nutrition philosophy? *

Do you have any physical conditions that might limit your ability to work long, irregular hours, or to perform tasks required of a midwife? *

Yes

If yes, please explain.

Have you ever been convicted of a felony? *

Yes

What position(s) are you applying for? *

Observer (Doula/Phase 1)

Assist (Phase 2)

Primary (Phase 3)

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