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!)
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.)
New Member Membership Renewal 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!
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
Solo practitioner/proprietor Partnership Group Practice (# of Midwives?_____) employee of a government, private non-profit or for-profit organization?
Are you training apprentices? Yes 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? Yes No
What was your educational route to midwifery knowledge and skills? (P=Primary S=Secondary)
Apprenticeship Self Study
MEAC-Accredited School (name of school) _________________________________________________
Other Midwifery School or Program (name of school or program) ______________________________
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