STUDENT MEMBERSHIP FORM

I WANT TO JOIN! (Please print and mail this form for student membership and donations.)

NAME_______________________________________________________________________________

STREET ADDRESS____________________________________________________________________

CITY_____________________________STATE/PROV___________ ZIP/POSTAL CODE_____________

HOME PHONE__________________________SECOND PHONE_______________________________

E-MAIL ADDRESS _____________________________

(When we use e-mail to communicate with you it lowers the overhead for the organization and protects our funds for other work.)

$___________ FEE ENCLOSED

$___________ Additional gift to NACPM-Any amount would be greatly appreciated!

$___________ TOTAL AMOUNT ENCLOSED

DEMOGRAPHIC INFORMATION

Are you a student member of? (Circle all that apply)   MANA   ACNM   CfM   ICTC State midwifery organization

Age: ____ 18-29 _____ 30-39 _____ 40-49 _____ 50-59 _____ >60

(Optional) Please describe your race. ____________________________________________

How long have you been studying midwifery? __________

When do you anticipate completing your studies? ___________  

Are you enrolled in a MEAC-accredited program? checkbox Yes   checkbox No    If yes, which one? _________

Are you apprenticing with a CPM ?    checkbox Yes   checkbox No

Will you become licensed/certified in your state ?   checkbox Yes   checkbox No

What credential(s) are you seeking? _______________________

What are your concerns as a student? _________________________________________________

Are there areas of importance to you as a student that you would like to see NACPM work on? Continue on back of this form if needed. WE LOOK FORWARD TO HEARING FROM YOU AND WE APPRECIATE YOUR SUPPORT!

________________________________________________________________________________

Signature___________________________________________________________________

Name (please print)____________________________________Date_________________

Please mail this form with your check or money order made out to NACPM to:

Susan Smartt
PO Box 506
Ooltewah, TN 37363