MEMBERSHIP FORM

I WANT TO JOIN/ RENEW! (Please print and mail this form for membership and donations. NOTE: this form will print two pages long--please be sure to complete it in full!)

NAME_______________________________________________________________________________

STREET ADDRESS__________________________________________________________________

CITY_____________________________STATE/PROV___________ ZIP/POSTAL CODE________

HOME PHONE__________________________OFFICE PHONE_______________________________

CPM CERTIFICATION# ________________E-MAIL ADDRESS_____________________________

(When we use e-mail to communicate with you it lowers the overhead for the organization and protects our funds for other work.)

DUES

checkbox New Member         checkbox Membership Renewal         checkbox Returning Former Member

$___________ $125 Annual NACPM Membership

$___________ $ 85 If you are a member of another state/national midwifery group

Please circle all that apply: MANA   ACNM   CfM   ICTC   State Organization ________

$___________ $ 75 Family income less than $35,000

$___________ Additional gift to NACPM-Any amount would be greatly appreciated!

$___________ TOTAL AMOUNT ENCLOSED
We encourage you to join at the $125.00 level to support the work of NACPM to advance opportunities for CPMs. We thank you for your support!

DEMOGRAPHIC INFORMATION

Are you a member of? (Circle all that apply) MANA ACNM CfM State midwifery organization

Age: ____ 20-29 _____ 30-39 _____ 40-49 _____ 50-59 _____ 60-69 _____ 70-79 _____ >80

How many years have you actively practiced midwifery? __________

Type of practice. (P=primary; S=Secondary) _____ Home _____ Birth Center _____ Hospital

(P=primary; S=Secondary) _____ Rural (pop < 5,000) _____ Urban/Suburban

checkbox Solo practitioner/proprietor     checkbox Partnership    checkbox Group Practice (# of Midwives?_____)   checkbox employee of a government, private non-profit or for-profit organization?

Are you training apprentices?    checkbox Yes   checkbox No    If yes, how many? _________

In which states are you licensed/registered/documented to practice midwifery? Pleases list all states in which you hold a license to practice and your title in that State.

1._________________________ 2._________________________ 3._________________________

Do you sit on your state’s regulatory board?    checkbox Yes   checkbox No

What was your educational route to midwifery knowledge and skills? (P=Primary S=Secondary)

checkbox Apprenticeship       checkbox Self Study

checkbox MEAC-Accredited School (name of school) _________________________________________________

checkbox Other Midwifery School or Program (name of school or program) ______________________________

Signature___________________________________________________________________

Name (please print)____________________________________Date_________________

Please mail this form with your check or money order made out to NACPM to:

Erin Ellis, CPM
628 E. Fridley Street
Bozeman MT 59715