Midwifery Preceptor Application Form
There are three (3) components to become a midwifery clinical preceptor in the Midwifery Education Program at Ryerson University:

• submit the Midwifery Preceptor Application and two (2) reference letters
• complete the online New Preceptor Education Program Reading Package and Quiz
• attend the New Preceptor Webinars and/or Workshop (offered by Zoom each year in the Fall term - a recording can be made available at other times)

Once these components are complete, you will receive a Midwifery Clinical Preceptor Certificate and you can be designated as a MEP preceptor.

Please note you must enter your email address below. You will receive a copy of this application form for your records. You will be able to return to the form and edit it after you press submit. You cannot save and return to the form so please complete it in one sitting.
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Email *
Part I: Personal and Practice Information
First and last name
Home address including street, city and postal code
Cell phone number
Pager or answering service (leave blank if not relevant)
Preferred email address for MEP communications if different than above
Name of current midwifery practice
Midwifery practice email address
Name of hospital(s) where you have privileges
Do you have privileges at the Toronto Birth Centre?
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CMO registration number
First date of registration with the CMO
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DD
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YYYY
Date of current CMO registration certificate
MM
/
DD
/
YYYY
Current CMO registration class
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If you are a New Registrant, when do you expect to complete your NR year? (leave blank if not relevant)
What education program did you graduate from?
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Part II: Referee Information
Please arrange for two references from people who can comment on your potential to be a clinical teacher in the Midwifery Education Program. These can be midwifery practice members, students you have worked with, midwifery clients or anyone else who you feel is suitable. List the names and contact information for your referees below. The link to the Midwifery Preceptor Reference Form can be found on the MEP website. Please refer your referees to the Becoming a Midwife tab on the following web page: https://www.torontomu.ca/midwifery/Clinical-Teaching-Learning/for-preceptors/
Referee 1: Name and position, e.g. RM
Referee 1: Email address
Referee 1: Phone number
Referee 2: Name and position, e.g. RM
Referee 2: Email address
Referee 2: Phone number
Part III: Declaration of Good Standing
In order to be a preceptor in the Midwifery Education Program, you are required to be a Registered Midwife in good standing with the College of Midwives of Ontario and with the hospital(s)/birth centre where you have privileges.

If you are uncertain about the status of your CMO registration or hospital/birth centre privileges or if you have limitations or current proceedings with the CMO or hospital where you have privileges, please contact Experiential Learning Coordinator Loreto Freire (GTA) or Martha Sharpe (GOA) at midwiferyplacements@torontomu.ca
I am in good standing with the College of Midwives of Ontario and eligible to practice with no limitations or current proceedings before the registration, discipline or fitness to practice committees.
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I am in good standing with the hospital(s)/birth centre where I have privileges with no restrictions or current proceedings.
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I declare that my answers to the above questions are true by placing my initials in the text box below.
I agree to inform the MEP if my CMO registration and/or hospital(s)/birth centre privileges status changes by placing my initials in the text box below.
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