CAPPA CHILDBIRTH EDUCATOR TRAINING

Please select the training you wish to attend *

Name *

First Name Last Name

What would you like to be called at training? What name should appear on your name tag? *

How should your name appear on your certificate of attendance? *

Email *

example@example.com

Phone Number *

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

How did you hear about this training? *

Please list any experience or employment in a birth related profession *

Please list any birth related training and/or certification/credentials *

Have you attended births other than your own? *

Yes No

If so, briefly describe your role and experience.

What do you wish to learn at this training? *

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/ccce-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.