2016 Basic Midwifery Student Scholarship Application

Transcription

1 PURPOSE: The A.C.N.M. Foundation, Inc. Basic Midwifery Student Scholarships are awarded to midwifery students to support education expenses for the purpose of encouraging individuals to pursue or complete basic midwifery education, thereby increasing the number, quality and diversity of certified nurse-midwives and certified midwives. Several basic scholarships are given annually, including the following endowed scholarships: Midwives of Color-Watson Scholarship, GlaxoSmithKline Consumer Health Care Scholarship, and the Edith B Wonnell CNM Scholarship. Memorial Scholarships are also awarded as funding allows. All applicants are judged on academic excellence, financial need and leadership potential criteria. AWARD AMOUNT: $3, APPLICATION DEADLINE: MARCH 1, 2016 ELIGIBILITY REQUIREMENTS ALL APPLICANTS: Be enrolled as a student in good standing in an ACME-accredited or pre-accredited basic midwifery education program Have successfully completed one academic or clinical semester/quarter or clinical module Be a current member/student member of the American College of Nurse-Midwives (ACNM) Agree to complete a brief data collection form within one year, if an award is received. Eligibility for selected endowed scholarships can be found in Part 1c, page 3. COMPLETE APPLICATIONS MUST INCLUDE THE FULLOWING: Part 1 Applicant Information Part 2 Applicant Statement Part 3 Educational and Professional Background Part 4 Statement of Career Goals & Plans Part 5 ACNM Leadership Activities & Plans Part 6 Financial Information Part 7 Program Director or Faculty Recommendation Form [To be submitted under separate cover] Part 8 Program Director or Faculty Letter of Recommendation regarding leadership potential [To be submitted under separate cover] Applications and Recommendations may be submitted by , fax or mail to: The A.C.N.M. Foundation, Inc. foundation@acnmf.org PO Box Fax: (617) Cambridge, MA Telephone: (240) Page 1 of 9

2 PART 1: Applicant Information PART 1a: Applicant Name and Contact Info Name: Credentials: Street: Current Address: City: State Zip code Country Phone: Home: Cell: Fax: Part 1b: Midwifery Education Program/ACNM Membership Midwifery Education Program Status: Full Time: Part Time: Start Date: Expected Graduation Date: ACNM Membership #: ACNM Region #: Page 2 of 9

3 PART 1c: Eligibility Requirements for Selected Endowed Scholarships: Midwives of Color Watson Basic Scholarship Do you self-identify as a student midwife of color? Yes No Edith B. Wonnell, CNM Basic Scholarship Upon graduation, do you intend to work in an out-of-hospital setting, i.e., birth center or home birth? PART 2: Applicant Statement If awarded an A.C.N.M. Foundation, Inc. Basic Midwifery Student Scholarship, I agree to the following: I certify that the information above concerning my eligibility for specific scholarships and my statement of financial needs in Part 6 is a complete and accurate assessment. I will submit a brief data collection form within one year as specified in an award letter I will acknowledge The A.C.N.M. Foundation, Inc. in any professional activities, including presentations and publications, which directly result from the scholarship. Applicant signature: Date: Page 3 of 9

4 PART 3: Educational and Professional Background PART 3a: Education Basic Nursing School Degree GPA Baccalaureate Graduate Other PART 3b: Professional experience, beginning with most current position (Attach additional page if needed) Agency / Facility: Position: Dates: Page 4 of 9

5 PART 3c: Professional organization memberships Organization: Office: Dates: PART 3d: Professional/academic honors Organization Description Dates PART 3e: Professional activities (research, publications, lectures, workshops) Title Location Dates Page 5 of 9

6 PART 4: Statement of Career Goals and Plans State your 5-year career plan(s) related to your practice of midwifery (150 words or less). Page 6 of 9

7 PART 5: ACNM Leadership Activities & Plans: State your current and/or intended future participation in the local, regional, and/or national activities of the American College of Nurse-Midwives (150 words or less). Page 7 of 9

8 PART 6: Financial Information PART 6a: Statement of Financial Need Briefly state your need for financial assistance to successfully complete your midwifery education (150 word maximum). All pertinent information will be considered. PART 6b: Intended Use of Funds: If you were to receive a $3000 scholarship from A.C.N.M. Foundation, Inc., how would you use these funds? (100 words or less). Page 8 of 9

9 PART 7: Program Director or Program Faculty Recommendation Form This form must be completed by the applicant s Midwifery Education Program Director or a member of the Midwifery Education Program Faculty with sufficient information to answer the questions below. Separate letters of recommendation addressing applicant s leadership potential are encouraged. Applicant Name: Midwifery Education Program: Director/Faculty Name: Does the applicant meet the following A.C.N.M. Foundation Basic Scholarship eligibility requirements? Enrollment in an ACME-accredited midwifery program? Yes: No: (please explain) Good academic standing? Yes: No: (please explain) Successful completion of one academic or clinical semester/quarter or one clinical module? Yes: No: (please explain) Rate the applicant s academic and clinical performance thus far in your midwifery education program. [1=lowest rating, 5=highest rating] Rate the applicant s potential for leadership in midwifery and professional contributions to ACNM [1=lowest rating, 5=highest rating] Signature: Date: Submission Instructions: Please submit separately from the student s application, Recommendation Forms and Supplemental Letters (via , fax or mail) by March 1, The A.C.N.M. Foundation, Inc. PO Box Cambridge, MA foundation@acnmf.org Fax: (617) Telephone: (240) Page 9 of 9