Your Name (required)
Current Address: City: State: Zip Code:
Your Email (required)
Previous Education: Year Name of School or Educational Program Certificate/Diploma/Degree
Previous Experience: (nurse, doula work, childbirth education, etc)
Midwifery Associations/Memberships:
Why do you want to become a Certified Professional Midwife?
Give us a short bio about yourself and what has inspired you to become a midwife: (You may share your own birth experiences, educational experiences or anything you feel is important.)
Please tell us why you are applying for this scholarship? (Financial hardship, children, missionary work, etc)
References: Give three references of people who can attest to your character. This can be midwives you have worked with or previous employers or people who know you. Name Phone Number Address Relationship
Y/N If you are not the recipient of this year’s scholarship will you still enroll in a midwifery educational program and pursue a career in midwifery? YesNo
Y/N Have you ever been enrolled in another midwifery educational program?YesNo
You must agree to the following: I understand that submitting my application does not guarantee that I will be a recipient of a scholarship to Via Vita School of Midwifery.
I understand that the Via Vita – Sharon Evans Scholarship is not transferable to any other schools or midwifery educational programs and is only available for the Via Vita School of Midwifery.
I understand that there is a non-refundable application fee of $50 to apply for this scholarship.
If I should be the recipient of this scholarship, I understand that I must complete the program and pass the NARM by January 2024.
Signed: Date:
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