The National College of Midwifery strongly believes that the culturally sensitive, client centered, individualized care that midwives provide has the potential to bridge health disparities and counteract institutional racism and discrimination within maternity care systems.  NCM strives to take part in this important work by making midwifery education accessible to students of underserved populations who are passionate, willing and prepared to effectively serve the communities with which they identify.

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* 1. Name

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* 2. Date

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* 3. Mailing address

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* 4. Phone #

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* 5. Email address

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* 6. Briefly describe your experience with and understanding of health disparities and institutional racism/discrimination as they relate to maternity care.

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* 7. Briefly describe the midwifery care you are current delivering.  Include demographic of those served, average number of clients per month, and what makes your practice unique.

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* 8. Briefly describe any work you are currently doing in your community that augments your connection to the population and makes your work as a midwife more effective.

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* 9. How do you see that the midwifery care you are providing can help to bridge health disparities as they relate to race and socioeconomic status?

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* 10. Explain how you personally identify with the population you are currently serving, what inspires you to want to serve it, and how you are qualified to offer culturally sensitive care in this particular demographic.

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* 11. Please describe your plan for completion of the NCM program.  Include agreements you hold with your preceptors, amount of time you plan to complete the program, what other significant activities you will engage in (if any) during the course of your studies.

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* 12. What other financial resources will you be drawing on in order to complete the NCM program? Please provide a detailed description of your financial plan including employment, family/community support, savings, financial agreement with clinical preceptors, living expenses, books and supplies, etc.  Include your annual family income and number of household members.

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* 13. Please attach a CV that lists all of your relevant experiences, including dates, location, roles/responsibilities held and degrees earned. Include any relevant education, employment, community service, publications, media coverage, life experiences.

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* 14. Please have 3 letters of reference sent to marcya@midwiferycollege.org

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