Membership Enrollment – Conservative Midwives Organization

Membership Request Form

All information provided in this form is for exclusive use of the Conservative Midwives Organization and will not be shared with third parties. Once becoming a member, we will not publicly list you as a member of the Conservative Midwives Organization without your authorization.

Your Name *

Certification details/other certificationsType here specifications about your certification and/or other certifications that are not listed above.

Institution and year of certification *Organization, School, or Hospital that issued your primary certification and year of graduation/issue.

Name of your practice (if private)

Practice Location *County where you are based or Street Address of your practice

StateState where your are currently practicing or where your licensed originated. Type "none" if you practice outside of the United States.

Practice ZIP code

Country If Non-U.S./International practitioner

Do you practice in more than one state?YesNo

Email Address *

Phone *

Website

Would you be interested in assuming leadership roles in the organization?YesNoMaybe

Optional: What would you like the organization to do for midwives and/or women?

Would you like to participate in the Feminine Bond Program?YesNoI need more informationThe Feminine Bond Program is a directory that connects conservative clients with conservative midwives and other women's health professionals.

Read and mark all to agree with the Terms and Conditions *I certify that the information provided above is true and that I am the person represented in this form. I am aware that the information provided in this form will be kept private and is exclusively used for membership and contact of the Conservative Midwives Organization.I understand that my information will be reviewed by the Conservative Midwives Organization Board, and that I might be contacted to provide additional information.I understand that I will not be considered an official member until my form is approved by the board. I authorize the Conservative Midwives Organization to contact me through the email or phone number provided above.I understand that this free membership expires in November 2021 and that I might need to renew my membership every year at the updated membership fee. Your application will be rejected if not all terms and conditions are marked.

Membership Request Form

All information provided in this form is for exclusive use of the Conservative Midwives Organization and will not be shared with third parties. Once becoming a member, we will *not* publicly list you as a member of the Conservative Midwives Organization without your authorization.

All information provided in this form is for exclusive use of the Conservative Midwives Organization and will not be shared with third parties. Once becoming a member, we will not publicly list you as a member of the Conservative Midwives Organization without your authorization.