Name
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First Name
Last Name
What is your preferred name?
What is your preferred pronoun?
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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Country
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Email Address
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How did you hear about National Midwifery Institute, Inc.?
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Qualified applicants will be admitted without discrimination in regard to sex, race, marital status, ethnic origin, creed, age, sexual orientation, or physical dis/ability. Students must have a high school diploma or equivalent. Students self-select, based on their own assessment of personal interest and motivation. The following questions are for information only and will not be used for admitting purposes. Do you have any physical or mental impairments that may be incompatible with midwifery practice? Please note if you’re unsure and we will contact you for clarification.
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Have you attended Heart & Hands Intensives with Elizabeth Davis?
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If you have completed Beginning/Intermediate Heart & Hands, please enter your date of completion below.
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If you have completed Advanced Heart & Hands, please enter your date of completion below.
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Please indicate where you completed high school or the equivalent.
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An official high school transcript or equivalent, sent directly from the granting institution, is required to complete enrollment. Please request that your transcript be sent directly to NMI, PO Box 863 Middlebury VT 05753.
Are you currently enrolled in a midwifery school or program?
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If so, please provide us with the name of the midwifery school or program and its location.
For each completed midwifery course (or course within a midwifery curriculum) that you intend to transfer to NMI, please provide the following in addition to the names, locations and dates entered below: 1) A working copy of your transcript (PLUS an official transcript sent directly from the midwifery program to NMI, PO Box 863, Middlebury VT 05753, or nmioffice@nationalmidwiferyinstitute.com; 2) Course descriptions from the school, and; 3) Learning objectives for courses completed.
Why are you leaving your current midwifery program?
What do you hope NMI will provide for you?
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Have you previously completed midwifery course work or instruction with a midwifery school or program?
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If so, please provide us with the name(s) of the midwifery school(s) or program(s), location(s), and dates enrolled
For each completed midwifery course (or course within a midwifery curriculum) that you intend to transfer to NMI, please provide the following in addition to the names, locations and dates entered below: 1) A working copy of your transcript (PLUS an official transcript sent directly from the midwifery program to NMI, PO Box 863, Middlebury VT 05753, or nmioffice@nationalmidwiferyinstitute.com; 2) Course descriptions from the school, and; 3) Learning objectives for courses completed.
How many semesters or quarters of midwifery course work have you completed?
Do you have a current preceptor? Potential preceptor? If so, who?
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Do you have a student relationship with a preceptor that will continue after you leave your current program?
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Are there midwives practicing in your area?
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Would you be willing to relocate for an apprenticeship opportunity?
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Assist Initial Prenatal exams:
Assist Prenatal exams:
Assist Births:
Assist Newborn exams:
Assist Postpartum exams:
Supervised Student Primary Initial Prenatal exams:
Supervised Student Primary Prenatal exams:
Supervised Student Primary Births:
Supervised Student Primary Newborn exams:
Supervised Student Primary Postpartum exams within 5 days:
Supervised Student Primary Postpartum exams occurring after 5 days post-birth:
Supervised Student Primary Care Births in out-of-hospital settings:
When do you intend to graduate from NMI?
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Where do you wish to practice midwifery as a graduate of our program?
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Is there anything else that you would like us to know about you?
Following your submission of this application form and $250 application fee, the next step in the enrollment process is an admissions interview. What are some good days and times to reach you by phone for a 30 minute-1 hour phone conversation?
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