Membership Form

To become a member:

  • complete the form below
  • click Submit at the bottom of the form
  • a confirmation email will be sent to you
  • mail your payment to the address shown on the email
  • once your payment is received your membership will be activated
  • a user id and password will be sent to you via email

MEMBERSHIP TYPE * This section must be completed.
 
   

Doula CARE 1 Year Membership
October 1st - September 30th
Total: $40.00 (early bird rate valid until September 15th)

 
 
   

½ Year - After April 1
Renewable as of October 1 of the same year
Total: $25.00

 
 
   

Training Special (applicable if you join in the same month as your training)
Renewable at $45 per year as of October 1st in the same year of your training
Total: $25.00

 
 

AGREEMENT OF MEMBERSHIP * This section must be completed.
 
  Our Mission Statement:
Doula C.A.R.E Inc. is an association that recognizes birth as a key life experience, the memory of which should be nurtured and protected. As an association, Doula C.A.R.E. Inc. is committed to providing access to emotional and physical support for families, and creating a positive and informed birth experience. 		 
 
   

By submitting this form, I hereby agree to abide by the Statement of Goals, Code of Ethics, and Standards of Practice as laid out by DoulaC.A.R.E Inc. in accordance with the World Heath Organization’s (WHO) International Code of Marketing Breast milk Substitutes.

 
 
   

I agree to uphold the DoulaC.A.R.E. Inc. Mission Statement, the privilege of confidentiality and to participate in the volunteer labour support program as determined by the members of DoulaC.A.R.E.Inc.

 
 
   

I hereby state that all information provided to DoulaC.A.R.E. Inc. regarding my qualifications and experience are accurate to the best of my knowledge.

 
 
  Statement of Goals | Code of Ethics | Standards of Practice  
 

CONTACT INFORMATION * required fields
 
  First Name*:    
  Last Name*:    
  Organization/Company Name
(if applicable)*:		    
  Address (Line 1)*:    
  Address (Line 2):    
  City*:    
  Province*:    
  Postal Code*:    
 
  Home Phone*:    
  Work Phone*:    
  Cell Phone:    
  Pager Number:    
  Email*:    
  Website:    
 
  Select your DoulaCARE Regional Group
(for DoulaCARE purposes only) :		    
 

TRAINING INFORMATION
 
  Labour Doula    
  Organization:    
  If Other, Please Specify:    
  Trainer Name:    
  Certification:   Certified Not yet certified Not practicing  
  Certification Date:    
  Experience (# of births):    
  Experience (years):    
  Fees:   $  
  If sliding scale, please indicate range:   $ to $  
 
 
  Postpartum Doula    
  Organization:    
  If Other, Please Specify:    
  Trainer Name:    
  Certification:   Certified Not yet certified Not practicing  
  Certification Date:    
  Experience (# of clients):    
  Experience (years):    
  Fees:   $ /hr  
  If sliding scale, please indicate range:   $ to $  
 
 
  Antepartum Doula    
  Organization:    
  If Other, Please Specify:    
  Trainer Name:    
  Certification:   Certified Not yet certified Not practicing  
  Certification Date:    
  Experience (# of births):    
  Experience (years):    
  Fees:   $  
  If sliding scale, please indicate range:   $ to $  
 

REFERRAL INFORMATION
 
  Are you currently taking referrals?  
  Yes
  No
 
 
  Do you want to be included on the referral line?  
  Yes
  No
 
 
  Do you want to be included on the website?*  
  Yes, all information
  Yes, but exclude the following information:
Name Address (Line 1)
Organization Address (Line 2)
City Province
Postal Code
Home Phone Work Phone
Cell Phone Pager Number
Email Website
Profile
  No
 
 
  Please note: The website and profile information is currently disabled and will not be visible from the "Find a Doula" search.  
 
  Profile:    
 
  Note: Doula C.A.R.E. Inc. is not responsible for misuse of our directory by non-members.  
 
  Select up to 10 areas you currently service  
 
1
2
3
4
5
6
7
8
9
10
 
 
  Our preference is to communicate with our members via e-mail. May we send you information by email?  
  Yes
  No, specify your preference
   
 
 

ADDITIONAL DESIGNATION(S) AND SKILLS
 
  Note: If selecting yes, please provide details.  
 
  Massage  
  Yes     No
 
  Certified / Registered?    
 
  Health Care Provider  
  Yes     No
 
  Field/Practice    
 
  Childbirth Educator  
  Yes     No
 
  Organization    
 
  Lactation Consultant  
  Yes     No
 
  Organization    
 
  Languages Spoken other than English  
  Yes     No
 
  Which languages?    
 
  Counseling  
  Yes     No
 
  Specify    
 
  Additional Breastfeeding Training  
  Yes     No
 
  Organization/Details    
 
  Strong Religious Ties  
  Yes     No
 
  Describe    
 
  Other  
  Yes     No
 
  Describe    
 

VOLUNTEERING
 
  Please indicate your preferred contribution method(s) to Doula C.A.R.E.:  
 
  Board of Directors
(2 year committment)		  
  Yes     No
 
 
  Volunteering at Baby Shows  
  Yes     No
 
 
  Fundraising  
  Yes     No
 
 
  Committee Member for special projects  
  Yes     No
 
 
  Contributing/Writing to Newsletter  
  Yes     No
 
 
  Other (please specify)    
 
  In addition to the Doula C.A.R.E. volunteer program, are you interested in working with non-paying clients?  
  Yes
  No