The College of Midwives of Alberta (CMA), Application for Initial Registration Subscription Personal Info

Application for Initial Registration Personal Info

PERSONAL INFORMATION

First Name *

Last Name *

Middle Name

Previously Known as

Gender

Date of Birth

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CONTACT INFORMATION

Address

Address Line 1 *

Address Line 2

City *

Country *

Province/State *

Province/State

Postal/Zip *

Primary Phone

Phone Ext

Secondary Phone

Secondary Phone Ext

Communication Email *

Public Email

(select all that apply)

Languages Spoken

BUSINESS INFORMATION

Mentor

Select your practice from the drop-down list. If your practice is not in the list select "OTHER" and complete the following fields with the appropriate information.

Practice Name

Fill in only if you selected OTHER above.

Name of Practice

Business Address

Address Line 1

Address Line 2

City

Country

Province/State

Postal/Zip

Business Phone

1. Are you currently working in a MARP situation?

Yes

2. Are you currently providing Continuity of Care, as defined by:

Yes

3. Are you currently involved as a midwifery student preceptor, new registrant mentor, or an Internationally-educated midwife supervisor?

Yes

4. If “Yes”, do you have an affiliation agreement with the Midwifery Education Program, or the CMA?

Yes

Education

Level of Midwifery Education

Granting Institution

Year Awarded

City

Province

Country

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Additional Education

Level of Midwifery Education

Granting Institution

Year Awarded

City

Province

Country

Additional Education

Level of Midwifery Education

Granting Institution

Year Awarded

City

Province

Country

Education(Canadian equivalency)

Level of Midwifery Education

Granting Institution

Year Awarded

City

Province

Country

AHS PRIVILEGES

AHS PRIVILEGES1

Name of Facility

Date Granted

Date Removed

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ADDITIONAL AHS PRIVILEGES

Name of Facility

Date Granted

Date Removed

ADDITIONAL AHS PRIVILEGES

Name of Facility

Date Granted

Date Removed

ADDITIONAL AHS PRIVILEGES

Name of Facility

Date Granted

Date Removed

ADDITIONAL AHS PRIVILEGES

Name of Facility

Date Granted

Date Removed

ADDITIONAL AHS PRIVILEGES

Name of Facility

Date Granted

Date Removed

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Username *

Password *

Password Confirmation *