2017 Jeanne Raisler International Award for Midwifery

Transcription

1 PURPOSE: To honor the memory of Jeanne Raisler, CNM, DrPH, FACNM and her commitment to midwifery and international women s health issues, this award supports midwives to become involved in global midwifery issues. This monetary award will enable the recipient to gain experience in international midwifery through participation in a project designed to improve the health of women in a developing country. AWARD AMOUNT: $3, APPLICATION DEADLINE: September 30, 2017 ELIGIBILITY REQUIREMENTS: Be a CNM/CM or a student enrolled in an ACME-accredited midwifery program with an anticipated graduation date on or before July 1, Be a member of the American College of Nurse-Midwives (ACNM). Have expressed interest in global midwifery issues. COMPLETE APPLICATIONS MUST INCLUDE THE FOLLOWING: Part 1: Applicant Information Part 2: ACNM Membership / Certification Part 3: Midwifery Education Program / Graduation Date Part 4: CV / Resume Part 5: Prospective International Agency Part 6: Proposed Project (Parts A, B & C) Part 7: Proposed Budget Part 8: Raisler Award Responsibilities Agreement Part 9: ALL APPLICANTS - Two (2) Recommendations to be submitted under separate cover Part 10: STUDENTS - Program Verification Form to be submitted under separate cover Completed applications must be submitted no later than September 30, 2017 by , fax or mail to: The A.C.N.M. Foundation, Inc. PO Box Cambridge, MA foundation@acnmf.org Fax: (617) Telephone: (240) Page 1 of 10

2 PART I: APPLICANT INFORMATION Name: Credentials: Street: Current Address: City: State: Zip code: Country: Phone: Home: Cell: Fax: PART 2: ACNM MEMBERSHIP/CERTIFICATION ACNM Membership #: Year Certified by ACNM/AMCB (Student Applicant-Expected Date) AMCB Certification #: (CNM/CM Only) AMCB Certification Expiration Date: PART 3: MIDWIFERY EDUCATION PROGRAM/GRADUATION DATE Educational Institution / Program Name: Graduation Date: (Student Applicants give Expected Date) STUDENT APPLICANTS MUST SUBMIT A COMPLETED PROGRAM VERIFICATION FORM (INDICATING ANTICIPATED LAST SEMESTER OR QUARTER ENROLLMENT) SEE PART 10. PART 4: CV / RESUME Attach a copy of your current CV/Resume. Page 2 of 10

3 PART 5: PROSPECTIVE INTERNATIONAL AGENCY International Agency Name: International Agency Contact: Address: Street: City: State: Zip code: Country: Telephone: Fax: Agency Description: (250-word maximum) Page 3 of 10

4 PART 6: YOUR PROPOSED PROJECT A. Briefly describe your proposed project. (250-word maximum) Page 4 of 10

5 B. Describe how your proposed project will advance international midwifery, your clinical skills in an international setting and/or relevant research. (250-word maximum). Page 5 of 10

6 C. Provide three (3) measurable objectives for your proposed project. Page 6 of 10

7 PART 7: PROPOSED BUDGET (Not to Exceed $3,000 US Dollars). List all anticipated expenses related to your project, including fees for visa, travel expenses to and from airports, flight costs, and other financial expenses. Page 7 of 10

8 PART 8: RAISLER AWARD RESPONSIBILITIES AGREEMENT If awarded at Jeanne Raisler International Award for Midwifery, I agree to: Provide verification of the international agency with which I will be affiliated. (Include such items as agency brochures, website, promotional materials); may attach electronic link. Obtain my own Passport/Visa and any other documents for travel to/from my home country for the international experience as required. Maintain all necessary professional licensing and certification required throughout the project. Submit a written account of the experience to The A.C.N.M. Foundation within 3 months of the conclusion of the experience. Signature: Date: PART 9: PROFESSIONAL RECOMMENDATIONS (USE FORM IN PART 9) All applications must include two (2) professional recommendations (using form in Part 9) from among the following: a professional mentor, faculty member, professional colleague, governmental or non-governmental official. PART 10: STUDENT APPLICANTS ONLY PROGRAM VERIFICATION (USE FORM IN PART 10) Student applications must include a Program Verification Form (Part 10) Page 8 of 10

9 PART 9: RECOMMENDATION FORM This award will be made to a Certified Nurse-Midwife (CNM), Certified Midwife (CM), or Student Midwife enrolled in an ACME-accredited program enabling the recipient to gain experience in international midwifery through participation in a project designed to improve the health of women in a developing country. Applicant Name: 1. How long have you known the applicant and how? (i.e., professional mentor, faculty member, professional colleague, governmental or non-governmental official) 2. Describe the applicant s strengths related to this award (described above). 3. Describe the applicant s leadership potential. 4. Does the applicant have the capability and flexibility to successfully gain experience in a developing country with regard to midwifery practice, education or research? (Please explain) Name: Signature: Title/Position: Date: Submission Instructions: Your verification MUST be received (by , fax or mail) by September 30, The A.C.N.M. Foundation, Inc. PO Box Cambridge, MA Page 9 of 10 foundation@acnmf.org Fax: (617) Telephone: (240)

10 PART 10: PROGRAM DIRECTOR VERIFICATION FORM STUDENT APPLICANTS Student applicants for the Raisler Award must be enrolled in an ACME-accredited midwifery program with an anticipated graduation date on or before July 1, This form must be completed by the applicant s Midwifery Education Program Director and submitted directly to the Foundation Office (see below). Applicant Name: Midwifery Education Program: Director Name: Does the applicant meet the following Jeanne Raisler International Award for Midwifery eligibility requirements? Enrollment in an ACME-accredited midwifery program? Yes: No: (please explain) Good academic standing? Yes: No: (please explain) Anticipated graduation date on or before July 1, 2017? Yes: No: (please explain) Anticipated Graduation Date: Signature: Date: Submission Instructions: Your verification MUST be received (by , fax or mail) by September 30, The A.C.N.M. Foundation, Inc. PO Box Cambridge, MA foundation@acnmf.org Fax: (617) Telephone: (240) Page 10 of 10