Doula Workshop Registration Form

Registration Form

Please fill in the form below.
Full Name *

First Name Last Name
Please select the training you wish to attend *
What would you like to be called at training? What name goes on your nametag?
How should your name appear on your certificate of completion?

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mobile Number *

- Area Code Phone Number
E-mail *
How did you hear about this training? *
Please describe your personal birth history (how many, your experience). *
How many births, other than your own, have you attended? *
Do you have experience in (choose all that apply): *

Vaginal birth Cesarean section VBAC (Vaginal Birth After Cesarean) Unmedicated birth Medicated Birth Homebirth Hopital birth Birth Center
Have you ever experienced or witnessed a traumatic birth? If so, please describe briefly. Please describe what steps you have taken to process and heal from the trauma. *
What other birth-related experience and/or certifications do you have? (LLL Leader, Childbirth Educator, Lactation Consultant, etc.) *
Please briefly describe your education and training, birth-related or otherwise. *
Current employment? Prior employment? *
Do you speak any language, other than English, fluently? Please list language(s). *
CAPPA membership *
How much of your required reading list (part of the CAPPA certification process) will you have completed before training? Please list the books you have read. *
Would you characterize your learning style as primarily: *

Visual Auditory Kinesthetic
What do you hope to learn from this course? *
Do you have any allergies of which the group should be aware as we will be sharing snacks? *
I verify that all of the information given in this application to register for the workshop is true. I affirm that I am at least 18 years old. I understand that training registration is not complete until payment has been received by Debbie Hull (return to https://www.debbiehulldoula.com/ld-payment-page.html and select the appropriate option). I understand that I am not registered until I have received confirmation from debbiehull.doula@gmail.com. I further affirm that by filling out and submitting this form, I agree to the terms and conditions as given above. My typed name in the space below is In lieu of a physical signature and indicates my agreement to these terms. *
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