MARIE GOUBRAN MEMORIAL AWARD Nominations

Please indicate (√) under which category this nomination is being made:

Clinical Practice Education

Name of Nominee..........................................................................................................................

Title: Mrs., Miss, Ms, Prof., Dr., Mr................................................................................................

Address ........................................................................................................................................

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Telephone No. Fax No.

(Please include international dialling codes)

E-mail.

Professional Qualifications ...........................................................................................................

Professional Organisation ............................................................................................................

(If in membership)

Post Currently Held (work) ...........................................................................................................

Indicate Nominee’s usual language...............................................................................................

In which other language(s) are you / is nominee fluent ? (please list) ..........................................

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Is this nomination supported by the Midwife Association?…………………………………………

The names, addresses and telephone numbers of two referees / supporters must be provided

1.............................................................. Name ......................................................................... Address ...................................................... .................................................................... .................................................................... .................................................................... Telephone No: ........................................... Fax No: ....................................................... E-mail: ........................................................ Professional relationship to nominee.......... .................................................................... Signature……………………………………

2. ......................................................... Name ...................................................................... ...................................................... Address .................................................................... ................................................................. ................................................................. ................................................................. Telephone No: ........................................ Fax No: .................................................... E mail: ..................................................... Professional relationship to nominee....... ................................................................. Signature…………………………………

Please enclose the Nominee’s curriculum vitae (not more than two pages) or briefly describe her/ his / your career and practice as a midwife

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In no more than 500 words explain why you feel the Nominee should be awarded the ICM Marie Goubran Memorial Fund Grant or Scholarship; describe how the Award monies would be spent to improve midwifery practice / education in the country or region of the nominee:

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This Section to be completed if the Nominee is not a self-nomination

Please print clearly in Black ink or typescript

Nominated by:

Name ...........................................................................................................................................

Address ........................................................................................................................................

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Telephone No:

Fax No:

E-mail:

Signature _________________________________________ Date ______________________

Please return the completed form by 15 October, 2001 to ICM Headquarters.

Information / Guidance

8. ICM Marie Goubran Memorial award

· There was a mutual agreement by the Board of Management of the International Confederation of Midwives, Dr. Gaby Goubran and his sons that two awards will be given at Congress.

· To make this possible we need your help.

· The Terms of Reference are included for your information and guidance.

· Please complete this nomination form with the name of the midwife you select to receive one of these awards.

· Please send the completed form to the Headquarters by the 15 of October 2001.

Marie Goubran Memorial Fund

Terms of Reference for the Award.

Purpose: To assist in the furthering of midwifery education and practice in countries with special needs and limited funding opportunities, through the provision of grants, scholarships and awards to midwives who have demonstrated the potential to act as change agents in their region or country.

Awarded: Every three years and announced at the International Council meeting

Selection process: The amount to be awarded to be determined by the Board of Management the preceding year.

There will then be a call for nominations from member associations.

The nominee need not be a member of the nominating association but may be a midwife unable to join any association in the country where she/he is in practice.

Selection Committee: The Board of Management of the International Confederation of Midwives, together with a representative of Mary Goubran’s family. They would have the power to co-opt the President of ICM and/or another midwife with special knowledge of maternity care world-wide.

Report: A detailed report is required to be submitted to the Board of Management six months after receipt of the award and at intervals thereafter as specified by the Board until conclusion of the award monies.