Personal Information

Name

Business Name

Address

City    State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip

Home Phone Cell Phone

Email

 

Birth Experience/Certification

Workshop Taken

When (Month/Year)

Where (City, State)

Are you Certified? Yes No

Date of Certification

Certified Doula #

Certifying Organization

Are you interested in volunteer opportunities? Yes No

Number of Births attended: 1-5 6-10 11-15 16-20 21-25 26-30 31+

Additional Training (CEU's)

List any related certifications you have (CBE, LMT, etc.)

 

Work/Referral Information
(Optional, Answer only what you feel potential clients might use to screen for a doula prior to calling her directly.)

What geographical areas do you cover?

Do you have a car? Yes No

Do you have religious restrictions? (please describe)

Do you have schedule restrictions? (please describe)

What is your fee? Is it Negotiable? Yes No

Do you offer a payment plan/sliding scale? Yes No

Do you have a web page? (list address)

Do you want to be listed on any referrals list available to DACO and/or birth professionals?
Yes No

If any organization wants access to our mailing list, would you like to be included?
Yes No

Please list any other services your offer.

How will you pay - You will have the oportunity to pay via Paypal after you click submit below.
Mail a check or money order
Paypal (will include an additional $5.00 charge to help pay Paypal fees.)

Please read the Membership Agreement before submitting your application.