2018 Basic Midwifery Student Scholarship Application
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- Vivien Ryan
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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: FEBRUARY 1, 2018 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 FOLLOWING: 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 - Please direct your Director or Faculty to the following site to submit their recommendation: Applications 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 8
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 8
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 8
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 8
5 PART 3c: Professional organization memberships Part 3c - Organization: Part 3c - Office: Part 3c - Dates: PART 3d: Professional/academic honors Part 3d - Organization Part 3d - Description Part 3d - Dates PART 3e: Professional activities (research, publications, lectures, workshops) Part 3e - Title Part 3e - Location Part 3e - Dates Page 5 of 8
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 8
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 8
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 8
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