Today's Date______________________ Miami Program Boulder, Colorado Program
Name____________________________________________________________________________
Street Address_____________________________________________________________________
City_______________________State__________Zip_____________ Date of Birth______________
Phones: Home________________________________ Work_______________________________
Sex: Male / Female Social Security Number_____________________________________
Weight___________ Height____________ Eye Color____________ Hair Color____________
Racial Designation (Optional):___________________ Religion (Optional)_______________________
Do you speak another language besides English fluently? Yes / No Which one (s)_____________
_________________________________________________________________________________
Have you had any illnesses in the past 5 years____________________________________________
Have you had any accidents in the past 5 years____________________________________________
Have you ever had an injury on the job? (if so - date, place and nature?)________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have you ever been convicted of a felony? If yes, please explain:_____________________________
_________________________________________________________________________________
As an aid in determining the work you can best do, please state any known physical impediment,
such as heart disease, high blood pressure, back or leg problems, you might have. Medicines?
_________________________________________________________________________________
EMERGENCY CONTACT
Name___________________________________________________________________________
Street Address____________________________________________________________________
City_________________________State_________Zip___________Relationship_______________
Phones:Home________________________________ Work________________________________
EDUCATIONAL BACKGROUND
High School: Name________________________________________Year Graduated___________
Address__________________________________________________________________________
GED_________ College Yes / No If yes, name of institution________________________________
Address__________________________________________________________________________
Number of Years_______or Terms_______ When_______ Degree(s)_________________________
Vocational or other Special Training____________________________________________________
_________________________________________________________________________________
REFERENCES
Please provide the names, addresses and phone numbers of the people whom you have asked to send
letters of recommendation.
Name____________________________________________Phone__________________________
Address_________________________________________________________________________
Name____________________________________________Phone__________________________
Address_________________________________________________________________________
Name____________________________________________Phone__________________________
Address_________________________________________________________________________
Name____________________________________________Phone__________________________
Address_________________________________________________________________________
ESSAY QUESTIONS
Please attach separate sheets of paper to answer the following questions.
1. Why do you think you would make a good midwife?
2. What are your goals after graduation?
3. Describe briefly your life experiences relating to pregnancy, birth, midwifery, and women's health care.
4. Describe your immediate family and your support system. Include children's ages and names, if any.
5. If you plan to commute from outside of the area, how many miles round trip?
6. If you plan to move, will your family be moving with you?
Essay Questions (continued)
7. How will you support yourself while studying? Do you plan to be employed during the program? If yes,
how many hours per week do you plan to work? Will you have flexible work hours for class, study,
and be on call for births?
8. Do you have realistic goals and the finances to meet them?
9. Do you have a car that runs well?
10. Do you have flexible hours to be on call for births?
Applying For
I am applying for:
_____ The Midwifery Training Program (3 years, 7 semesters)
_____ The Midwifery Training Program for Nurses (2 years, 5 semester)
_____ The Foreign Trained Refresher Course (4 months)
Signature and Date
All of the above information provided in this application for admission is true and accurate to the
best of my knowledge. I understand that should I furnish any false information, this would be
grounds for dismissal from the International School of Midwifery, Inc.
Signature___________________________________________ Date________________________
_______________________________________________________________________________
