Application for Practitioner & Instructor Program

Applications will not be accepted after August 15, 2014.
Your application will be reviewed when all of the following items have been received:
- Completed application
- Uploaded essay
- Uploaded photograph
- Letter of reference sent directly by your chosen referee


Please select the program for which you are applying:
PractitionerAuditor (Practitioner)Instructor (limited responsibilities

Name

SIN

Date of birth

Sex FemaleMale

Email

Home Phone

Cell/Work Phone

Home Address

Mailing Address (if different than above)

Primary language

If you are fluent in other laguages, please list them


EDUCATION HISTORY
Provide a list of all educational institutions which you have attended and are currently attending, beginning with high school.

Name of Institution Location Start Date End Date Program Credential Initials
1
2
3
4
5
6
7


OCCUPATIONAL HISTORY
Provide a complete list of occupations beginning with your most recent. If never employed outside the home, proceed to the next section

Organization Role Start Date End Date Responsibilities Reason for leaving
1
2
3
4
5
6
7


VOLUNTEER WORK
Have you ever performed volunteer work? (specify below)


FAMILY PLANNING INVOLVEMENT
Have you worked in any of the following capacities in a Natural Family Planning (NFP) Program?

Role Yes/No Full/Part Time Start Date End Date
Medical Advisor
Nurse Practitioner
Program Director
Teacher Coordinator
Secretary/Bookkeeper
Consultant
Other


Where have the NFP Services been provided?

Location Title Spaced Rented or Donated


In what method(s) of Natural Family Planning do/did you commonly provide instruction?

What other method(s) of family planning do/did you recommend to clients?

Which of the following educational formats do (did) you commonly use? Press "Ctrl" while selecting with mouse to make multiple selections.

Which of the following practices do/did you encourage? Press "Ctrl" while selecting with mouse to make multiple selections.

Have you had a physician working with you (at all) in your NFP work?
(explain the physician's role below)

If a physician has worked with you, provide name and address of physician

What form of training have you received up to now?

If informal, semi-formal or formal training received, where and by whom were you trained?

What was the duration (in hours or days) of your training?

If previously certified, provide the name(s) of certifying individuals/organization.

How useful has your training been?

In what areas do you feel your training has fallen short of your needs? Press "Ctrl" while selecting with mouse to make multiple selections.

If "Other," please specify


COMPLETE THE FOLLOWING SECTIONS EVEN IF YOU HAVE NOT PREVIOUSLY BEEN INVOLVED IN NFP

How important do you consider the following provider attributes? 1=Absolutely Not Important, 2=Not Important, 3=Important, 4=Very Important

Female
Female in reporoductive years
A Natural Family Planning user-acceptor
A user-acceptor of the NFP method being taught
Married
Married with children
Well educated
Well trained in NFP
Confident in NFP
Confident in NFP method being taught
Willing to refer for psycho-social counseling (e.g., marriage, family)
Willing to refer for medical problems
Willing to refer for artificial contraceptive methods
Willing to refer for induced abortion
Similar social class/background to that of client
Similar age to that of client
Socially acquainted with clients (e.g., same church, same community)
A medical orientation
A family orientation
Stable in paritcular vocation
Open to criticism and failure
Non-judgmental/supportive
Friendly/cheerful


CONFIDENTIAL/PERSONAL INFORMATION

Do you prescribe or refer for contraceptives, sterilization or abortion?
NoYes

Do you perform or refer for artificial technologies?
NoYes

Do you practice (use) natural family planning, or if single and celibate, are you a philosophical acceptor of natural family planning?
NoYes


DECLARATION

Two new organizations have been introduced: FertilityCare™ Centers of America, and FertilityCare™ Centers International. These new organizations are designed to unite CREIGHTON MODEL FertilityCare™ Centers nationwide and worldwide. Please note: any Practitioner or Center must become an affiliate or participate in an affiliated program to order CREIGHTON MODEL FertilityCare™ System teaching materials for client instruction.

It is important for your understanding of this program that you read, electronically sign and date the following:

I understand upon completion of the FertilityCare Toronto Practitioner Education Program, in order to purchase CREIGHTON MODEL FertilityCare™ System teaching materials, I will need to become an affiliate or participate in an affiliated program with FertilityCare™ Centers of America or FertilityCare™ Centers International.

Electronic Signature (type full name) Date


Indicate if you will be teaching with an existing FertilityCare™ Center or establishing a new center once you complete the program.
(name)


ATTACHMENTS

A. Essay: Answer the following essay question in approximately 500 words, and upload your essay using the "browse" button below:

“Why is teaching the CREIGHTON MODEL FertilityCare™ System and providing professional FertilityCare™ services important to me?” (Discuss your motivation for seeking to become a FertilityCare Provider, why you have chosen professional training in this system, and the goals you have set for yourself.)


B. Please attach a recent photograph of yourself using the "browse" button below. (Max size: 900kb)


LETTER OF REFERENCE

Select a referee and arrange for him/her to send one letter of reference directly to the Education Program Director:
Margaret Smith RN, CFCE, Education Program Director
c/o FCT – Education Department
Suite 100 - 688 Coxwell Avenue
Toronto, ON M4C 3B7
CANADA

Application information will be used for evaluating applicant acceptance, not for treatment purposes.
The application will be kept as part of the Education Program’s academic or continuing education’s records.


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