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Student Midwife Indexing Application Form

This document is an application form for individuals seeking to be indexed as student registered midwives in Ghana. It includes sections for personal data, educational background, next of kin information, and a declaration of adherence to regulations. Additionally, it requires certification from the head of the training institution and specifies necessary documents to accompany the application.

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annabelesmith41
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72 views1 page

Student Midwife Indexing Application Form

This document is an application form for individuals seeking to be indexed as student registered midwives in Ghana. It includes sections for personal data, educational background, next of kin information, and a declaration of adherence to regulations. Additionally, it requires certification from the head of the training institution and specifies necessary documents to accompany the application.

Uploaded by

annabelesmith41
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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FOR OFFICE USE ONLY

NMC – ACCOUNTS DEPARTMENT


RECEIPT NO _________________
AMOUNT GH¢______________
DATE _________________
SIGNATURE _________________

APPLICATION TO BE INDEXED AS A STUDENT REGISTERED MIDWIFE (TOP-UP)


Personal Data
Surname Date of Birth DD/MM/YYYY

First Name Home Town


Other Names District
E-mail Region
Mobile phone number Nationality
Address
Postal Address
e.g. P. O. Box KB 1234, Korle-Bu, Accra.
Permanent Home Address
e.g. H/No. 124/N12, Tema, Community 2.

Educational Background
Educational Qualification
e.g. Senior High School
Secondary School Attended
SHS programme option Aggregate Obtained e.g 18

Next of Kin
Name Relationship
Mobile phone number E-mail
Postal Address
Declaration
I agree to observe and be bound by the Regulations governing Registered Midwiferytraining as laid down by the
Nursing and Midwifery Council of Ghana (Code of conducts for Nurses &Midwives, Clinical Schedule Book and Rules
and Regulations governing the Council’s Licensing Examinations)
Date Signature
DD/MM/YYYY

Certification of Training(To be completed by the Head of Institution or Representative)


I certify that (Name of Applicant) __________________________________________________________________
Is known to me and that the particulars given by the applicant are to the best of my knowledge, correct.
I recommend that his/her name be entered into the index of Registered Midwives in training.
Date training commenced:_________________________________________________________________________
Name of Head of Institution ____________________________________ Signature _______________________
Academic and Professional Qualification _____________________________________________________________
Training Institution______________________________________________________________________________

Date _____________________________________
___________________________________________________________________________________
Stamp

NOTE: Application must be accompanied by


(1) Copy (or copies) of Auxiliary Nursing / Midwifery Certificate
(2) A copy of Birth Certificate
(3) Two (2) recent passport size photographs (red background) in uniform endorsed by Head of Institution
(4) Prescribed indexing fee
(5) A copy of admission letter - For Universities only (Degree Awarding Institutions)

It is advised that indexing should be completed by the end of the first semester of the first year of training.

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