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Midwife To Be International Project
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* Indicates required question
trip interested in
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Dominican Republic
Mexico
Other:
Name
*
Your answer
Project start date
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MM
/
DD
/
YYYY
Full address
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Your answer
Phone (cell)
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Your answer
Email
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Your answer
Date of birth
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MM
/
DD
/
YYYY
Other Language besides English?
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Your answer
Number of children
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Your answer
Married?
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Yes
No
Religion?
Your answer
License you hold (RN, EMT, CPM, etc.)
Your answer
Health problems?
Your answer
Do you have a current passport?
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Yes
No
Previous 3rd world trips?
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Yes
No
Primary Emergency Contact Information
Name
*
Your answer
Phone
*
Your answer
Email
*
Your answer
Primary Refrence/ preceptor etc
Name
*
Your answer
Phone
*
Your answer
Email
*
Your answer
Please write out a paragraph explaining why you want to go.
*
Your answer
I am interested in going as:
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Beginner Midwife student
Advanced student (ready to deliver babies-with preceptors permission ) May not get catches
Non-licensed midwife
LM (1/2 of fees required)
CPM (1/2 of fees required)
CNM (1/2 of fees required)
MD (1/2 of fees required)
Shift leader (if Midwife or MD with trip experience) No preceptor fees required
Doula
Other:
Students from 2019 trip practicing skills in our break room
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