Apply to attend our Two Weekend Workshop

the total cost for both weekends is 1275 if paid in full
two or three payment options available

payment link will be sent if application is approved

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Name *

First

Last

Email *

Facebook URL (so we can add you to the group):

Phone *

Home/Shipping Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Present 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 Study
• Attend a Program
• Completed a Program

Practice Status: (check any that apply) *

• Apprentice
• Practicing Doula
• Practicing Birth Keeper
• Practicing Midwife
• None of the Above

Are you currently a practicing Traditional Midwife or Direct Entry Midwife? *

• Yes
• No

If yes, for how long?

Are you currently an apprentice? *

• Yes
• No

If so, how long and at what skill level? *

Do you plan to pursue CPM certification? *

• Yes
• No

Do you plan to become licensed or certified to practice in your state? *

• Yes
• No
• Undecided

If you are not currently practicing or apprenticing, are you looking to gain apprenticeship or placement? *

• Yes
• No

If yes, tell us more about your plans/goals.

Are you a Doula or a Child Birth Educator? *

• Yes
• No

If yes, who are you certified through?

Is midwifery legal in the state/country you plan to practice in? *

• Yes
• No

Is 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? *

• Yes
• No

Are you a part of your state midwifery organization(s)? *

• Yes
• No

If yes, name of organization.

If no, tell us why.

What other courses/workshops have you taken? *

Are you NRP certified? *

• Yes
• No
• I will be by the time of the workshop

Enrollment Agreement

I understand and agree to the following: initial each line to indicate you have read and understand each statement

Foundational 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 statement

I 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. *

• Yes
• No

Signature

Clear Signature

Submit my application