Attach head shot photo here 1 APPLICATION FOR ADMISSION Direct Entry Midwifery Program APPLICANT INFORMATION Date Changes Address Last First Middle Please provide documentation for any name other than the name provided above that you have used. (i.e. driver s license, marriage decrees, passport ) City State & Zip Email Phone Number Social Security Number Date of Birth How did you hear about FSTM? Have you attended an Aspiring Student Meeting? Yes No If yes, please indicate date & location Applying for a start date of: Fall 2016 Registered Nurses: If the Applicant is a currently licensed Registered Nurse (RN) FSTM will automatically grant 17 advanced standing credits. My RN License number is: Are you a United States Citizen Yes No Is English your second language? No Yes Languages other than English fluently spoken or read? Per Florida Statute: http://www.flsenate.gov/laws/statutes/2012/chapter467 Have you ever been convicted of a felony? No Yes
2 EDUCATIONAL BACKGROUND Required: Applicants must include the full name & address information for all academic and vocational schools attended beginning with high school. High School School / City / State Diploma ~ Degree Completion Date If no degree, why? City State & zip code College City State & zip code Vocational Schools City State & zip code EMPLOYMENT / VOLUNTEER INFORMATIOM Please list employment and/or volunteer positions held within the last 3 years. If you are or have been Self-Employed, please provide information about your business. : City: State & zip code: : City: State & zip code: : City: State & zip code: Employer Required:, Address and Phone # Position Title Dates Position Held Reason for Leaving
3 Please tell us about yourself! How did you find out about The Florida School of Traditional Midwifery? Why did you choose the Florida School of Traditional Midwifery? Why do you want to be a Midwife? What life experiences do you feel are relevant to attending midwifery school?
4 What are your goals for midwifery practice after completing your education at The Florida School of Traditional Midwifery? Do you have any previous midwifery related experience? If yes, please describe: Is there anything else that you would like to share about yourself?
5 LETTERS OF RECOMEMDATION Provide the name, address and phone number of three people, not related, who you have asked to complete a Letters of Recommendation on your behalf. We ask for very specific information therefore please use the FSTM Letter of Recommendation Form provided in the Application Packet. Reference # 1 Address Telephone # Relationship to Applicant Reference # 2 Address Telephone # Relationship to Applicant Reference # 3 Address Telephone # Relationship to Applicant
6 ADVANCED STANDING REQUEST/ INSTRUCTIONS FSTM does not accept transfer of credit; however Advanced Standing may be granted for students with relevant prior education. As mandated in Florida Statue 467, previous student education will be assessed on an individual basis. In no case shall the training be reduced to a period of less than 2 years (F.S.467.009{2}). Advanced Standing credits awarded will not count toward the maximum time frame for completing the program. Registered Nurses: If the Applicant is a currently Licensed Registered Nurse FSTM will automatically grant 17 advanced standing credits for the following FSTM courses: 1101, 1101L,1103,1201, 1201l 1203, 1203L, 2201,2201L, 2303 All requests must be made at the time of submitting this application. Requests for Advanced Standing will be evaluated by FSTM upon acceptance into the program. An Advanced Standing fee of $25.00 per credit will be assessed and is due and payable with the enrollment fee. Advanced Standing fees are non-refundable. The student will be notified of the advanced standing evaluation at enrollment. Required Documentation Applicants will be required to submit a sealed official transcript showing completion of any course material for which they are requesting Advanced Standing. In addition, you may be required to provide supporting documentation. 1. College catalog from the year in which the student was enrolled in the course. Clearly indicate which pages in the catalog are relevant. If you did not keep a college catalog, they are usually available on microfiche at the college library. In this case, provide a copy of the front cover of the catalog, the table of contents and the course description. 2. Syllabus from the course 3. If online website address where the college catalog and syllabi are available 4. Supporting documents may include, but are not limited to: A letter from the instructor of the course describing the course content Notes, assignments or exams from the course. Please check the section that applies to your Application I am requesting Advanced Standing Please sign below and continue to page 7 I am not requesting Advanced Standing. Please sign below, leave page 7 blank and continue to page 8 I am a currently licensed Registered Nurse (RN). Please sign below, leave page 7 blank and continue to page 8 Applicant Signature:
7 ADVANCED STANDING REQUEST FORM I understand that I am requesting Advanced Standing for the following courses/credits at The Florida School of Traditional Midwifery, as allowed per Florida Statute 467.009. I understand that my transcript will be assessed and that a $25.00 per credit processing fee will be charged per each advanced standing credit request(s). I understand that Advanced Standing Fees are non-refundable. Fees will be assessed per Enrollment at FSTM. I understand that no Advanced Standing requests may be made after enrolling in the program(s). Student must supply the originating college name and course code number. Please refer to the FSTM catalog/curriculum for FSTM course code number and course name. Originating College Transcript Florida School of Traditional Midwifery Code # Course FSTM Course Code # FSTM Course FSTM Credit Total Number of Credits Requested Applicant Signature:
8 REQUEST for ADMITTANCE I request consideration for admittance as a student to The Florida School of Traditional Midwifery. All of the information provided in this application for admission is true and accurate. I verify that I will be 18 years of age or older at the time of admission. I have reviewed and researched all information as it pertains to the practice of Direct Entry Midwifery. I also feel that I have a complete understanding of the practice of Direct Entry Midwifery in the State of Florida and what it means to be a Florida Licensed Midwife (LM) and a nationally Certified Professional Midwife (CPM). I understand that furnishing false information is grounds for my dismissal from The Florida School of Traditional Midwifery. Applicant Signature: Date: The Florida School of Traditional Midwifery (FSTM) Discrimination Policy: The Florida School of Traditional Midwifery (FSTM) does not discriminate on the basis of age, race, color, national and ethnic origin, sexual orientation, gender, disability, marital status and/or religion; FSTM grants to all the rights, privileges, programs and activities generally accorded or made available to any members of the organization. Thank you for completing an application to the Florida School of Traditional Midwifery www.midwiferyschool.org