CAPPA CBE/LD Combo Training

Sweet Miracles presents a CAPPA Childbirth Educator/Labor Doula Combo Training

Thank you for your interest in attending a CAPPA Childbirth Educator/Labor Doula Combination Training Workshop. To reserve your seat, please fill out the information below. A Paypal invoice will be sent to you upon receipt of this registration form.

Name (as it should appear on certificate)

Age

Preferred Nickname

Training Date and Location

Address 1

Address 2

City

State

Postal Code

Phone

Email Address

Do you need accommodation or travel information?

Yes

No

Number of personal birth experiences:

If you've had personal birth experiences, please briefly describe them here:

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Prior to your own births, did you attend childbirth education classes?

If yes, please describe type of class, what you found most helpful and least helpful, did you feel equipped and encouraged to birth?

0/2550 characters

Current Employment

Applicable birth field related skills, certifications or employment?

Are currently you a childbirth educator?

Yes

No

If yes, please list the types of classes and the amount of experience you have:

If yes: Organization

If yes, certified?

Yes

No

Are you a lactation consultant, LLL leader, or teach breastfeeding classes? (please specify):

Please briefly describe your education and training:

Have you witnessed or attended births other than your own?

Yes

No

If yes: Number of Births attended (excluding your own):

Please place an X if you have experience in:

Have you witnessed or experienced a traumatic birth?

Yes

No

If yes, please briefly describe that birth and what steps, if any, you have taken to heal from the trauma.

What do you hope to learn from this course?

What areas of Childbirth Education are you most interested in?

Certifications steps you plan to complete prior to the training (please place an X):

Required Reading

Become a CAPPA member

Audit Childbirth Education class

For Childbirth Educators: What Certification path do you plan to follow?

Traditional

Accelerated

I don't plan to certify

Include my contact information on lists distributed to other attendees.

Yes

No

How did you hear about this CAPPA training? (Please select all that apply.)

Cancellation Policy:

If Sweet Miracles (SM) cancels the workshop, the entire fee will be refunded.
The deposit of $250 is non-refundable unless SM cancels the workshop.
If the cancellation is made within three weeks of the workshop, no refund will be given.
With express written approval of the Director, payment may be applied to a SM workshop within 12 months. (If applicant does not attend a workshop within 12 months, all fees are forfeited.)

FEES:

Tuition ($695) for Chidlbirth Educator/Labor Doula combination training is to be directly paid to Sweet Miracles. Paypal is the accepted payment method. A Paypal invoice will be emailed to you within 2 business days after registering for the training. All fees are due 3 weeks prior to training unless other arrangements have been made with Louise DeLaney. A surcharge of $50 will be added to any tuition in the 21 days prior to start of workshop. The Childbirth Educator and Labor Doula manuals are included in the workshop fee price. CAPPA membership and the Certification packet are not included. Each may be purchased at the training.

TERMS:

As a participant of this training, I agree to allow SM to publish: my name, address, phone number, and email address for their trainee class list & referral list. I have read and agree to all terms of the SM cancellation policy. I verify that all of the information given in this application is true.
Take photographs of the training which may include me, as well as allow the trainer and CAPPA to use these photographs for promotional purposes online and in print.
Use quotes from my training evaluations (which I may fill out anonymously) for promotional purposes online and in print.

I verify that all of the information given in this application is true. I further affirm that by filling out and submitting this intake form electronically, I agree to the terms as given herein, in lieu of physical signature.

Please initial below to indicate that you agree with this statement.

Initial here:

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