*(denotes required field)

First Name: *

Last Name: *

E-Mail Address: *

Date of Birth (mm/dd/yyyy): *

Address: *

City: *

State: *

Zip: *

Cell Phone:

Home Phone: *

Business Phone:

Website:

Do you need accommodation or travel information for attending the workshop? *

Yes
No

Have you given birth to at least one child? *

Yes
No

Home Births:

0 1 2 3 4 5 6

Birth Center Births:

0 1 2 3 4 5 6

Hospital Births:

0 1 2 3 4 5 6

Children Breastfed: *

0 1 2 3 4 5 6 7

How long did you breastfeed each child? *

Briefly describe each birth and breastfeeding experience: *

Did you attend childbirth education classes prior to your own births? *

Yes
No

If yes, please describe how they equipped you for birth:

Are you currently a birth professional? *

Yes
No

If yes, please list the organization(s), certifications and licencing

# of couples served:

Current field of employment: *

Applicable birth field related skills:

Please select the types of births you have attended:

Vaginal Birth
C-Section
VBAC
Unmedicated
Medicated
Hospital
Birth Center
Home

What do you hope to learn at the Birth Boot Camp workshop? *

What areas of Childbirth Education would you like to see emphasized in the workshop? *

FEES: • Payment for the Birth Boot Camp Instructor Training Workshop is due in full 4 weeks before your scheduled workshop. This includes: - the workshop fee - teacher’s manual - a student copy of the workbook - certification packet - birth videos. Payment will be taken online when registering for training. • A $25 discount will apply if paying for the workshop in full at the time of registration. • A non‐refundable deposit of $400 is required to secure your spot at the workshop and will be applied toward your total fee. • Additional fees may include: - reading materials - teaching supplies - travel accommodations for training - etc.

Please select your preferred payment option: *

Payment in full ($25 discount applies)
$400 at time of registration and remaining balance due 4 weeks before workshop

CANCELLATION POLICY: • The deposit of $400 is required to hold your spot at the workshop and is non‐refundable. • If cancellation is made within two weeks of the workshop no refund will be given. • Payment will be applied to the Birth Boot Camp workshop chosen. If applicant desires to change their specified training date a $100 fee will be applied. All fees are forfeited if applicant does not attend a workshop within 12 months of applying. • If Birth Boot Camp cancels the workshop for any reason the entire fee will be refunded. *

2013 & 2014 BIRTH BOOT CAMP INSTRUCTOR TRAINING WORKSHOPS Please check the workshop you plan to attend: *

September 19-21 2013 - San Clemente CA - $775
October 17-19 2013 - Dallas/Fort Worth - $775
February 21-23 2014 - Houston TX - $895
June 19-21 2014 - Indianapolis IN - $895
October 16-18 2014 - Orlando FL - $895

TERMS: • I understand that all pre‐workshop requirements must be completed before attending the workshop. • As a participant of this training I agree to allow Birth Boot Camp to publish my information: - name - city - state - phone number - email address for the online web listing. I have read and agree to all terms of the Birth Boot Camp cancellation policy. I verify that all of the information given in this application is true. • I understand that photographs and video will be taken at the workshop which may include me. I agree to and allow Birth Boot Camp to use these photographs and video for promotional purposes online and in print. • I will allow Birth Boot Camp to use quotes from my training evaluations (which I may fill out anonymously) for promotional purposes online and in print. • Birth Boot Camp reserves the right to reject any applications for Instructor Certification.

By checking this box I verify that all of the information given in this application is true. I further affirm that I have read and agree to the terms given herein. *

Who can we thank for referring you to Birth Boot Camp? *

Birth Boot Camp offers a customized blog for all instructors. (a $50 fee applies) Would you like more information?

Yes
No

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