BCN Membership 2018
Thank you for your interest in becoming a Birth Care Network Member! Please complete the form below. Once submitted, please follow the instructions to complete your payment. Your membership listing will be updated on the site once both the form AND payment have been submitted. Membership renewal is required in March of each year and will begin taking place on March 1, 2019.

Membership WILL INCLUDE the following for each listing:

Name + Credentials (if applicable)*
Business Name (if applicable)*
Phone (unless specified to be masked below)
Email (unless specified to be masked below)

*hyperlinked to your website or facebook page (unless specified to be masked below)

We look forward to seeing you at the next meeting!

Name *
Your answer
Business Name (if applicable)
Your answer
Credentials
CD(DONA), LCCE, etc. This will follow your name in your listing.
Your answer
Certifying Organization
For each credential listed, list each certification and organization through which you hold a current certification in good standing. Ex. Birth Doula - DONA International. You may potentially be requested to provide a copy of the certificate.
Your answer
Website or Social Media Address
Your listing will be hyperlinked to this destination. Feel free to provide whichever social media platform you primarily use to engage with potential clients.
Your answer
Would you like your site included in your listing?
Phone Number (xxx-xxx-xxxx) *
Your answer
Would you like your number displayed in your listing? *
Email Address *
Your answer
Would you like your email included in your listing? *
Where should you/your business be listed on the website? *
You may check all that apply.
Required
If "Local Businesses and Resources"
Give a *brief* description of your service (ex Parent/Caregiver-Child Music Classes, Placenta Encapsulation, Infant/Toddler Nutrition & New Mom Support Group, etc)
Your answer
Membership Type *
Midwifery or Doula groups may choose to be listed individually, as a group or both. Please complete separate applications for the group and individual members.
Comments
Need to be listed in a specific area that isn't clear? (ie. massage therapist, photographer, yoga teacher, etc.) Have questions regarding membership?
Your answer
I understand that my membership application is not complete until I submit payment via PayPal.* *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.