Preceptor Application

This is the application for all ASM and BSM preceptors at NCM. There are 3 steps to completing the application process: 1) this application, 2) completion of the Preceptor Orientation course which includes uploading the preceptor agreements and documentation of your qualifications and 3) completion of the Safety and Learning Site Application.

This first step takes approximately 15 minutes to complete and must be completed in one sitting.

Preceptor Details

Only used for a more personal connection and has no influence on acceptance as a preceptor.

Note: For the purpose of this database entry, all faculty are considered academic. Therefore, even if you are only registering to be a clinical preceptor you will choose "academic".

Best number to contact you at.
For US Numbers please enter like this: (xxx)xxx-xxxx
For International Numbers please just input all # including country code without parenthesis.

Only used for verification purposes. Use the calendar or type in your date of birth (MM-DD-YYYY). To use the calendar, double click on the month at the top to access your year, month and date of birth.

A preferred pronoun is a pronoun an individual chooses to identify with and would prefer others use when talking to or about that individual. It is the pronoun that a person uses for themself.

For internal purposes only

Please provide the address at which you receive mail. This address is not necessarily the clinical practice address.

Select N/A if you have not yet earned a non-midwifery degree.

Select other if your non-midwifery degree is not specified in this list.

This field is used by the college to determine which preceptors require supervision in general education courses.

Select Midwifery if you graduated from a MEAC accredited school.

This field is used by the college to determine which preceptors require supervision in general education courses.

Certificate and License Information

Must be at least 2 years prior to today's date. Otherwise contact the office at info@midwiferycollege.edu.

Use the calendar or type in the date (MM-DD-YYYY). To use the calendar, double click on the month at the top to access your year, month and date.

If you are an ACADEMIC ONLY preceptor write that in this field please.

If your clinical location is not listed then NCM does not have permission to have students at this location at this time. Please contact Marcy at marcya@midwiferycollege.edu to discuss updating this list.

If you will not be doing ANY clinical experiences with your student then select No Clinical.

If you do not have a provider certificate or license and are only serving as an academic preceptor select NA.

NOTE: NCM only requires one Provider Certificate or License.

You will have the option to upload others in subsequent fields.

If you do not have a License or Certificate enter a date of 9/9/1999.

Use the calendar or type in your date (MM-DD-YYYY). To use the calendar, double click on the month at the top to access your year, month and date.

OPTIONAL: NCM only requires one Provider Certificate or License.

OPTIONAL: Type in any Other Healthcare Provider License or Certifications AND Expiration Date you wish NCM to be aware of.

Student Information

Write the first and last name of each student followed by the word "current". If you are applying to be NCM faculty before you have a student relationship, put "applying" in this field.

If you are applying to be BSM faculty only, put "NA".

For example:
Natasha Hill current
Kiko Nako current

Write the first and last name of each student followed by the word "current". If you are applying to be NCM faculty before you have a student relationship, put "applying" in this field.

If you are applying to be ASM faculty only, put "NA".

For example:
Natasha Hill current
Kiko Nako current

Write the first and last name of your student.

Other Opportunities and Quality Improvement

If you are interested, NCM will send you information about applying once the hiring process has begun.

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