CAPPA CHILDBIRTH EDUCATOR TRAINING

CAPPA CHILDBIRTH EDUCATOR TRAINING - SCHOLARSHIP RECIPIENT
Please select the childbirth educator 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 (answer not required for virtual trainings)?
I agree that Debbie Hull may use my image (from training), application essay, and announce my receipt of the scholarship on her website, Facebook page, and other social media.

Yes No
Copy the link and open payment page before submitting registration form: https://www.debbiehulldoula.com/ccce-payment-page.html.
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.
Should be Empty:

CAPPA CHILDBIRTH EDUCATOR TRAINING - SCHOLARSHIP RECIPIENT