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* 1. What is your name and the best phone number and email address for you?

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* 2. What city and state do you live in?

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* 3. What grade are you entering this Fall?

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* 4. Tell us what you enjoy doing for fun? Some examples might include games you enjoy, family/friend activities, self care, or anything else you would like to share!

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* 5. How would your friends/family describe you?

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* 6. Have you considered a career in healthcare? If yes, what type of career? (dentistry, nursing, therapy, doctor, EMT/CNA or any other career paths you have considered).

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* 7. Based off your own understanding, what do you think a midwife is? Try not to use the internet for this, only your prior knowledge.

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* 8. What would you want to learn about midwifery?

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* 9. We plan to meet one Saturday per month for 90 minutes from September to December. Will you be able to commit to this? 

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* 10. Will you be respectful of other participants and facilitators of the group?
What do you need from the facilitator to help us create a safe learning environment?

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