Application for Enrollment

Requirements for enrollment are:
• Must be at least 18 years of age
• Must have a minimum of high school or equivalent education

Last Name:
First Name:
Maiden Name:
Other Names you have used:

Current Address:
City:
State:
Zip Code:
Country:
Primary Citizenship:

Email Address:

Home Phone Number:
Cell Phone Number:

Marital Status:  Married Single

Children:ages:

Languages spoken:

How did you hear about Via Vita?

What will be your primary state or country of practice after you become a CPM?

Have you ever had a serious physical or psychiatric problems? If so, please explain:

Have you ever been involved in a lawsuit or complaint involving birth work in any way? If so, please explain:

Previous Education: (Degrees, certificates, college courses, workshops, doula training, childbirth education)
Year        Name of School or Educational Program        Certificate/Diploma/Degree

Previous Experience:
Year        Name of Organization/Preceptor        Experience/responsibilities

Any other notes about your prior training or experiences you feel is important:

Please describe any health or learning challenges that may impact your ability to learn and how you have dealt with those issues:

Write a short essay addressing the following questions
(Please feel free to write beyond these questions if you feel inspired to do so.)
1. Write about your introduction to midwifery and birth. What brought you to this path?
2. Why do you want to attend births outside of a hospital setting?
4. What makes you most excited when you imagine yourself as a practicing midwife?
5. What makes you most apprehensive when you imagine yourself as a practicing midwife?
6. Why do you think you will be an excellent midwife?
7. How will you need to grow in order to become an excellent midwife?
8. Why did you choose Via Vita School of Midwifery for your midwifery training?

References:
The Via Vita School of Midwifery requires two letters of recommendation from non-family members who have personal knowledge of you and can attest to your character, educational experience and potential to succeed. The letters must be submitted with your application. You will need to provide a list of names and contact information for each person from whom you have requested a letter of recommendation.
We suggest that you ask up to five individuals to send recommendations and provide each a stamped envelope addressed to Via Vita School of Midwifery, PO Box 580038, Houston, TX 77058. While the Via Vita may contact respondents to clarify or ask for additional information, it is not the responsibility of our staff to follow-up when letters are not received.

If accepted into the Via Vita School of Midwifery, LLC:
 My answers to course work, quizzes and exams will be my own work.
 I will not make solutions to course work, quizzes or exams available to anyone else. This includes both solutions written by me, as well as any official solutions provided by the course staff
 I will not engage in any other activities that will dishonestly improve my results or dishonestly improve/hurt the results of others.
 I will not give this course, in whole or part, to others who have not enrolled or paid tuition for this course.
 I will not attempt to practice midwifery without properly completing a midwifery educational program and any other requirements as outlined by my state or areas I plan to apprentice or otherwise reside.
 I understand that I will have four years from enrollment to complete this program unless arrangements are made with the Administrative Director for a leave of absence.

Date:

Signature:

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