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 ---12345678910111213141516171819202122232425262728293031 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924 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 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 2 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 3 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 4 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 5 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 6 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 7 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 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 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 2 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 3 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 4 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 5 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 6 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 7 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 VOLUNTEER WORK Have you ever performed volunteer work? NoYes (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 ---YesNo ---Full TimePart Time ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 Nurse Practitioner ---YesNo ---Full TimePart Time ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 Program Director ---YesNo ---Full TimePart Time ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 Teacher Coordinator ---YesNo ---Full TimePart Time ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 Secretary/Bookkeeper ---YesNo ---Full TimePart Time ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 Consultant ---YesNo ---Full TimePart Time ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 Other ---YesNo ---Full TimePart Time ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 ---JanFebMarAprMayJuneJulyAugSeptOctNovDec ---20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938 Where have the NFP Services been provided? Location Title Spaced Rented or Donated ---Private HomePublic BuildingChurch PremisesSocial AgencyHospitalIndependent NFP CentrePublic Health ClinicPublic Family ClinicOther ---RentedDonated ---Private HomePublic BuildingChurch PremisesSocial AgencyHospitalIndependent NFP CentrePublic Health ClinicPublic Family ClinicOther ---RentedDonated ---Private HomePublic BuildingChurch PremisesSocial AgencyHospitalIndependent NFP CentrePublic Health ClinicPublic Family ClinicOther ---RentedDonated ---Private HomePublic BuildingChurch PremisesSocial AgencyHospitalIndependent NFP CentrePublic Health ClinicPublic Family ClinicOther ---RentedDonated ---Private HomePublic BuildingChurch PremisesSocial AgencyHospitalIndependent NFP CentrePublic Health ClinicPublic Family ClinicOther ---RentedDonated ---Private HomePublic BuildingChurch PremisesSocial AgencyHospitalIndependent NFP CentrePublic Health ClinicPublic Family ClinicOther ---RentedDonated ---Private HomePublic BuildingChurch PremisesSocial AgencyHospitalIndependent NFP CentrePublic Health ClinicPublic Family ClinicOther ---RentedDonated 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. ---Introductory Lectures (Group)Introductory Lectures (Individual)Introductory Lectures (Group)Introductory Lectures (Individual)Phone Advising/CounsellingCorrespondence Counselling Which of the following practices do/did you encourage? Press "Ctrl" while selecting with mouse to make multiple selections. ---Client continuing with same teacherAttendance at session(s) by Spouse/partner/fiancéConference with other teachers to discuss difficult casesReferral for medical and/or counseling services when necessary Have you had a physician working with you (at all) in your NFP work? NoYes (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? Self trainingInformal trainingSemi-formal trainingFormal training 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? ---Extremely usefulUsefulNot sureLittle useNo use at all In what areas do you feel your training has fallen short of your needs? Press "Ctrl" while selecting with mouse to make multiple selections. ---Scientific basis of the method(s)Psychodynamics of use of the method(s)Human sexualityTeaching methodologyIn-service training and supervisionStudy of use of method(s) in various circumstances (e.g. breast-feeding, off birth control pill)Study of difficult casesOther (specify below): 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 1234 Female in reporoductive years 1234 A Natural Family Planning user-acceptor 1234 A user-acceptor of the NFP method being taught 1234 Married 1234 Married with children 1234 Well educated 1234 Well trained in NFP 1234 Confident in NFP 1234 Confident in NFP method being taught 1234 Willing to refer for psycho-social counseling (e.g., marriage, family) 1234 Willing to refer for medical problems 1234 Willing to refer for artificial contraceptive methods 1234 Willing to refer for induced abortion 1234 Similar social class/background to that of client 1234 Similar age to that of client 1234 Socially acquainted with clients (e.g., same church, same community) 1234 A medical orientation 1234 A family orientation 1234 Stable in paritcular vocation 1234 Open to criticism and failure 1234 Non-judgmental/supportive 1234 Friendly/cheerful 1234 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. I will be teaching with an existing FertilityCare™ Center: (name) I will be establishing a new FertilityCare™ Center 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. Please enter the characters into the field:
