Application For Instructor Certification Program

Instructor Application

Your Name

Your Email Address

Your Birthdate

Street Address

City

State

Zip Code

Country

Phone Number

Select a Training Workshop
---July 16-18, 2021 - SLC, UTJuly 30 - Aug 1, 2021 - Houston, TXAugust 16-19, 2021 - OnlineOctober 7-9, 2021 - OKC, OKOctober 14-16, 2021 - Buffalo, NYNovember 6-8, 2021 - Dallas, TXNovember 19-21, 2021 - Colorado Springs, CONovember 19-21, 2021 - Austin, TXDecember 13-16, 2021 - Online

How have your own birth experiences impacted your desire to be involved in childbirth education? If you do not have children, why do you want to become a Childbirth Educator?

Birth Boot Camp taglines promote “amazing birth” and “amazing support” for births. At the root of our philosophy is that the majority of women can birth their babies vaginally and without medication. Does your philosophy and attitude towards birth align with that of Birth Boot Camp?
YesNo

Are you currently a birth professional?
YesNo

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

Current Field of Employment

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

Who can we thank for referring you to the Birth Boot Camp Instructor Certification program?

Payment Information: There are two payments that will need to be made. 1) Certification Fee is paid to Birth Boot Camp to begin the program. 2) Training Fee is paid to the Instructor Trainer who will be conducting the workshop you choose to attend. Early Bird Fees are $295 Certification Fee and $600 Training Fee. After the Early Bird Deadline, fees are $330 Certification Fee and $665 Training Fee.
I understand that there are 2 separate payments that will need to be paid in order to complete my training as a Birth Boot Camp Instructor. I also understand that all fees are non-refundable.

CANCELLATION POLICY: All fees are non-refundable. If applicant desires to change to a later workshop date, a $250 fee will be applied. This $250 fee is due immediately to reserve the applicant’s spot in the new workshop.
I understand the cancellation policy

TERMS: • I understand that all pre‐workshop requirements must be completed before attending the workshop. • 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 refuse any applications for Instructor Certification.
I understand and agree to these terms

Non-compete/non-disclosure: Before completing your Birth Boot Camp instructor training, you will be asked to sign a non-compete/non-disclosure agreement. The Birth Boot Camp family is large and spread across the globe. Signing of the non-compete/non-disclosure simply ensures protection of the brand for all of the hundreds of other birth professionals that depend on the name for their own financial security. This does not prevent birth work, should you leave the company. It does, however, mean that upon signing, you agree not to intentionally harm the name of Birth Boot Camp, use copyrighted materials, conduct trainings or start a competing company. We are happy to answer any questions you may have.
I understand