AAM enrollment form | Ancient Art Midwifery

Name

First

Last

Pronouns

How did you hear about AAMidwifery?

Email - the one you check most often!

Alternate email - if you use paypal put that address here

Facebook profile URL (so we can add you to the student groups)

Phone - primary

Phone - secondary

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We want to send you some things!

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Address - shipping(if different)

Address Line 1

Address Line 2

City

State

Zip Code

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We want to get to know you...

Present occupation

Relationship Status:

Birthday

Ages of child(ren) if applicable

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You and your studies

Average number of hours you can commit to the course each week

How long have you been studying midwifery on your own?

What birth related websites, magazines or journals do you regularly read?

Will you have difficulty buying and/or borrowing a large number of books?

Yes
No

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Previous Education

Do you consider yourself, as a student, to be:

Below average
Average
Above average
Excellent

Other education

Graduation Date/Projected Graduation Date (from school listed above)

Post-secondary Education (if applicable):

Other (explain)

Post-secondary Schools attending/attended:

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If you have attended nursing school or are planning to attend, are you or will you become a CNM?

Yes, I am a CNM
No, I am not a CNM
I plan to eventually become a CNM
I have no plans to become a CNM
I am not sure if I will become a CNM in the future or not

Are you currently a practicing traditional, lay or direct-entry midwife?

Yes
No
Other

Are you currently an apprentice?

Yes
No

Do you plan to pursue your CPM credential?

Yes
No
I am not sure yet
I am already a CPM

Do you plan on becoming Licensed or Certified to practice midwifery in your state/country?

Yes
No
Not sure yet

If you are not currently practicing or apprenticing, do you foresee any difficulty in obtaining an apprenticeship?

Are you a Childbirth Educator or Doula?

Yes
No

If you answered yes to the above question, who are you certified with?

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Is midwifery legal in the state/country you plan to practice in?

Yes
No
Other:

Other (explain)

Licensing requirements, if any (please review your state laws regarding midwifery education. Note: AAMidwifery is not MEAC accredited):

Approximate number of practicing midwives in your state?

Approximate number of midwives in your local area?

Do you know any of them?

Yes
No

Is midwifery and homebirth well supported by the greater community in your area? (For example, are there supportive doctors, childbirth educators, allied health professionals, etc?)

Are you part of your state midwifery organization?

Yes
No

Name of state midwifery organization

Courses you plan to take concurrently with this one:

Do you know any AAMidwifery enrollees?

Yes
No

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Enrollment agreement

I understand and agree to the following (initial each box to indicate that you have read and understand each point.):

Ancient Art Midwifery reserves the right to accept or reject any applicant. A telephone interview will be required prior to approval.

All funds listed on the website and this page are in US Dollars.

All curriculum materials received during enrollment are the intellectual property of AAM and are not allowed to be copied or shared in any way.

Ancient Art Midwifery reserves the right to accept or reject any submitted work. Students will have the opportunity to re-submit work until it is accepted.

In addition to the stipulations above:

(Initial each statement below to indicate your understanding and agreement.)

I realize that there will be additional expenses not included in my enrollment. This includes, but is not limited to books, photocopying, postage, conference recordings, videos, and supplies.

I understand that this course is intended as preparation for, or complement to, practical experience under a supervising midwife. I will not, under any circumstance, misrepresent myself as a qualified birth attendant based on enrollment in, or completion of, this course alone. I am in complete agreement that my education will not be complete without an apprenticeship and/or other forms of practical experience. AAMidwifery may be able to provide assistance in locating a preceptor but cannot make that guarantee.

I understand that this course demands a great deal of time and study. What I learn depends on how much effort I invest.

I will not represent myself as an AAMidwifery graduate until I have the certificate in my possession.

Every requirement must be completed before a student becomes eligible for the Certification Exam. In addition, a score of 70% or higher on the MSAT (Midwifery Scholastic Achievement Test), as well as passing scores on the terminology, and proficiency exams must be achieved. All work submitted must be completed by the student only and may not be a copy of another student's work.

I understand that my enrollment period is limited and I will be assigned a PCD (Projected Completion Date) that is 48 months from my start date. I understand that my enrollment fee is for access to the program regardless of whether or not I choose to complete the program. While tuition is non-refundable I understand that sabbaticals may be requested and are granted only at the discretion of the director.

(Should you need to go beyond your PCD, extensions are available at an additional fee.)

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Submission of this form is equivalent to signing this document and shall be considered legally binding. Please print a copy of this completed form - prior to clicking the "submit" button - for your own records.

I have read the entire AAMidwifery website. I understand and agree to the stipulations of enrollment in Advanced Midwifery Studies. I have made the decision to enroll, fully aware that the course is comprehensive and therefore time consuming; that books are not provided with tuition; and that there will be no tuition refunds for any reason after the 36-hour right to cancel period has ended. Enrollment benefits officially begin immediately after the 36 hr right-to-cancel period ends, with the first instructions and links to the online coursework sent via email. Signing my name in the space below constitutes a legal signature. All course materials remain the property of AAMidwifery and may not be shared, copied or sold for any reason.

I HAVE READ AND UNDERSTAND THE ENROLLMENT AGREEMENT AND AGREE TO THE TERMS AND CONDITIONS PRESENTED HEREIN.

Clear Signature

Sign using your finger or mouse above to indicate that you've read and understood the agreement. This will be sent to you and stored by AAMidwifery and constitutes a legal signature.

You will receive a copy of this complete form to the email address you entered above. Please save this email for your records.

Non-refundable application fee to be submitted with this application:

Price: $75.00