Application for Enrollment – Bio Birth Midwifery Academy

Please enable JavaScript in your browser to complete this form.

Name

First

Last

Maiden Name

Other Names you have used

Current Address

City

State & Zip

Country

Primary Citizenship

Home Phone

Cell Phone

as most (Please

Marital Status

Married
Single

Children/ages:

Languages spoken

How did you hear about BioBirth Midwifery Academy?

What will be your primary state or country of practice after you become a CPM?

Have you ever had a serious physical or psychiatric or educational problem that may effect your ability as an intern midwife or professional midwife? If so, please explain:

Have you ever been involved in a lawsuit or complaint involving birth work in any way? If so, please explain:

Previous Education: (Degrees, certificates, college courses, workshops, doula training, childbirth education) Year Name of School or Educational Program – Certificate/Diploma/Degree

Previous Experience: Year Name of Organization/Preceptor Experience/responsibilities

Any other notes about your prior training or experiences you feel is important:

Write a short essay addressing the following questions (Please feel free to write beyond these questions if you feel inspired to do so.) 1. Write about your introduction to midwifery and birth. What brought you to this path?

2. What makes you most excited when you imagine yourself as a practicing midwife?

3. What makes you most apprehensive when you imagine yourself as a practicing midwife?

4. Why did you choose BioBirth Midwifery Academy for your midwifery training?

If accepted into the Via Vita School of Midwifery, LLC:

My answers to course work, quizzes and exams will be my own work.
I will not make solutions to course work, quizzes or exams available to anyone else. This includes both solutions written by me, as well as any official solutions provided by the course staff
I will not engage in any other activities that will dishonestly improve my results or dishonestly improve/hurt the results of others.
I will not give this course, in whole or part, to others who have not enrolled or paid tuition for this course.
I will not attempt to practice midwifery without properly completing a midwifery educational program and any other requirements as outlined by my state or areas I plan to apprentice or otherwise reside.
I understand that I have until the December 2029 to complete this program and pass the NARM exam. If I need longer than 4 years I will be required to complete the enrollment process again, including tuition and updating any answers that may be outdated so that I will be better prepared to pass the NARM exam and practice safely.

You must select all boxes

Date

Signature