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


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!



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!



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