Please copy the following questions into your preferred word processing application, answer them and turn them in by Sept 15th, 2017. 


Full Name


Phone number 

Email Address

Date of Birth


Are you married? If so, for how many years? 

Do you have children? If so, how many?

Highest grade of school completed

List all additional certificates, trainings and coursework that you have obtained or taken

Please list all hobbies and interests

Please list all social groups, and organizations that you belong to or have belonged to.

List all jobs from first to present

Please answer the following in one or two complete sentences. 


1. How many births have you attended?

2. How many home births have you attended?

3. Are you able to leave your family, at a moments notice, for up to 48 hrs at a time? 

4. Do you have any health or physical considerations that would prevent you from lifting heavy objects, holding and supporting a laboring woman (up to 250 pounds), staying up for long periods of time, massaging a laboring woman for hours at a time, walking up and down a flight of stairs several times a day. Not being able to perform these duties does not disqualify you as a candidate.

5. In order to gain skills, students need to practice. Students typically practice on each other. This includes blood draws, PAPS and pelvic exams. Declining to be a practice model for other students will not disqualify you as a student candidate. Will you decline to be a practice model for other students? 

6. Do you have any beliefs that would prevent you from compassionately serving women from different belief systems or lifestyles? A few examples:

Undocumented immigrants
Extremely wealthy
Extremely poor
Same sex families
Polyamorous/non-bianary families
Religiously intolerant
Extremely religious

7. Do you have any beliefs that would prevent you from providing unbiased and compassionate healthcare, support or education for services or circumstances that go against your belief systems? Just a few examples:

Artificial insemination for same sex parents,
Providing care to women who have many, many children,
Birth control,
Parental decline of male circumcision
Parental consent to male circumcision

8. To begin with, you will be attending clinic and classes Tuesday- 8 am - 9 pm, Wednesday 10 am - 6 pm and Thursdays 10 am - 3 pm. If needed, will you be able to arrange for childcare during these times?

Answers need not be long but they should clearly communicate your thoughts and be reflective of who you are as a potential midwife.

Why do you want to be a midwife? 

How do you see yourself serving your community? 

What do you feel are the most important qualities of a midwife? 

What do you think are some of the issues that women of color and new immigrants face that even typical midwifery does not address? 

What do you see as being your greatest challenges to being a student midwife? 

What support systems can be put in place to help you overcome those challenges? 

How would you respond to the following circumstances?


It is 3 am and your toddler has been throwing up all night. Your partner has a big meeting at work the next day. You are exhausted. The phone rings, you are being called to a birth. 


You are two births away from completing Phase 2 (clinical birth assistant) of your application. You are all dressed up and at a fancy restaurant, celebrating with your partner. You get called to a birth. Your partner understands and tells you that you better go. You drove in your husband's car and you don't have your equipment or regular clothes with you, so you have to drive home. You make it in time for the birth and work extra hard at cleanup since you missed most of the labor. However, your preceptor doesn't sign you off on the birth because you were not there to help set up or provide labor support. 


You have completed Phase 2 and are now working on Phase 3 (Midwife under supervision) and you are now being assigned your own clients. Another student from the center who is in Phase 2 has been hospitalized and cannot attend a birth. You are on your way to your child's parent teacher conference and your preceptor calls and asks if you would assist at this birth, a birth for which you will not receive clinical credit. 


One of your clients has missed 2 appointments because she does not have a ride to the clinic and getting her 3 kids who are under the age of 6 on the bus is too much of a hassle. It is 1 pm on the day of her 3 pm appointment and she calls to say that she can't make it. 


You are trying to understand a particularly difficult clinical concept but your preceptor is not teaching it in a way that you understand. 

Please provide name, relation, email address and phone number

1. Personal Reference
Submit one from of the following
Partner or roommate, family relative(s), friend

2. Professional Reference
Submit one from the following
Teacher or former employer, midwife, physician, associate, co-worker or client

Extra Points: 

1. Return application in by noon, Sunday, August 27th. 

2. Text Shell and let her know that you have received the link to the Student Folder


email your application to:

If you have any questions or need help with the application, text Shell at: