2024 CA workshop application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Facebook URL (so we can add you to the group):Phone *Home/Shipping Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePresent Occupation: *Birthday: *Ages of Children:How long have you been studying midwifery/birth? *What birth related websites, publications, etc do you read? *Midwifery Education Status: (check any that apply) *Self StudyAttend a ProgramCompleted a ProgramPractice Status: (check any that apply) *ApprenticePracticing DoulaPracticing Birth KeeperPracticing MidwifeNone of the AboveAre you currently a practicing Traditional Midwife or Direct Entry Midwife? *YesNoIf yes, for how long?Are you currently an apprentice? *YesNoIf so, how long and at what skill level? *Do you plan to pursue CPM certification? *YesNoDo you plan to become licensed or certified to practice in your state? *YesNoUndecidedIf you are not currently practicing or apprenticing, are you looking to gain apprenticeship or placement? *YesNo If yes, tell us more about your plans/goals.Are you a Doula or a Child Birth Educator? *YesNoIf yes, who are you certified through?Is midwifery legal in the state/country you plan to practice in? *YesNoIs midwifery/homebirth well supported by the greater community in your area? (for example: supportive transports, Doctors, Child Birth Educators, Allied Health Professionals) *Do you have relationships and support from the other midwives/doulas in your area? *YesNoAre you a part of your state midwifery organization(s)? *YesNoIf yes, name of organization.If no, tell us why.What other courses/workshops have you taken? *Are you NRP certified? *YesNoI will be by the time of the workshopEnrollment AgreementI understand and agree to the following: initial each line to indicate you have read and understand each statementFoundational Concepts for Midwives reserves the right to accept or deny any applicant. Referral by the host or an interview with Sarita and/or Rowan may be required prior to approval. *All funds listed on the website and in the registration page are in US dollars. *All curriculum materials received are the intellectual property of Foundational Concepts for Midwives and are not allowed to be copied or shared. *Initial each line below to indicate you have read and understand each statementI realize there will be additional expenses not included in the price of the workshop, ie: lodging, travel, childcare, dinners. *I understand that this workshop is intended as preparation for, or a compliment to, any midwifery schooling and practical experience under a supervising midwife. I will not, under any circumstance, misrepresent myself as a qualified birth attendant based on enrollment in, or completion of, this workshop alone. *I understand that this workshop is not refundable. If you cannot attend for any reason, your registration can be transferred to another student after they have completed this application and been approved or you can attend a future workshop. *I understand this is an application for attendance, admittance is not guaranteed and I will be notified of the decision by email. If I'm admitted I will receive a link to register for my chosen workshop in that acceptance email. *YesNoAre you willing to sign a confidentiality non-disclosure agreement in order to protect everyone in attendance, including yourself? Write out the word YES in the box below. Anything else will mean an automatic rejection of this application. *Signature Clear Signature Submit my application