*Name:                           

*Title, Certification, Education:  
(RN, BSN, LPN, doula, DONA, CCE, etc.)

*With which of the following organization(s) are you certified?
(press control and left mouse click to choose more than one) Please Choose.... ACOG ACNM ALACE ASPO/LAMAZE Birth Works Bradley Method/AAHCC CAPPA CCE DONA ICEA Other...
If "other," please specify here:   

*If you are an RN, LPN, and/or have a BSN, please tell us from which college/university you received your certification?
(type "n/a" if not applicable)       

*What is the name of your healthcare organization:   
(i.e. hospital name, clinic name, private practice, midwife, etc.)

*Street Address:                  
(no PO Boxes please, this will also be your shipping address for your starter kit)

*City:      *State: Select State... AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY D.C. PR US VI    *Zip:

*Phone:    *Fax:  

*Email: 

*Do you or your healthcare organization have a website? ... Yes No
If "yes," what is the website address?

*Who is the Director of your CB education programs? 

*What type of childbirth classes do you teach?       

*How many times per week?                                      

*Average number of attendees (expectant moms) per class?    

*Average number of attendees per year?                        

*Please tell us some demographic information about your class attendees.
(i.e. average age, income, race, etc.)                              

*Where do you teach your CB-related classes?       
(location, i.e. hospital name, clinic, home, private lessons, etc.)

*How many CE instructors are there in your organization?      

*Will this CEP account be shared by others in your organization?   .... Yes No

*Do you wish to purchase the LaborGear Bag at the CEP discounted price of $56.00?   .... Yes No   (S&H is $10.00)

*Do you wish to purchase the LaborKit at the CEP discounted price of $15.00?   .... Yes No   (S&H is $6.00)
 
(If "yes" please continue to the next field for payment information.  If "no," please click here to skip to the next section).

Payment Method:      ..... Visa MasterCard American Express
Card Number:             
Expiration Date:       Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC     Year 2001 2002 2003 2004 2005

Credit Card Billing Address:
Street:  (no PO Boxes please)
City:      State: Select State... AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY D.C. PR US VI     Zip:
Phone: 

Will the LaborGear Bag/LaborKit be used for in-class demonstrations?      ... Yes No

Will the LaborGear Bag/LaborKit be shared with other CE's in your organization? ... Yes No

Will you notify us if you ever decide to not use the LaborGear Bag/LaborKit for in-class demonstrations?     ... Yes No

How do you intend to use the LaborGear Bag/LaborKit?
         

*Will you make the LaborGear Bag brochures and order forms available to your class attendees before, during, or after your in-class demonstration?              ... Yes No

*Should we expect to receive orders or product inquiries for the LaborGear Bag as a result of your in-class demonstrations?   ... Yes No Hope So!

*Will you notify us if you ever decide to not use the LaborGear Bag brochures and order forms in-class?   ... Yes No

*How did you hear about the Famiy4Life CEP program? 
Please Select... referral from another CE referral from another DONA referral from another RN referral from director of your organization web search engines received direct mail friend healthcare publication/newsletter Pure Luck!  Found You Online Other

*Please give us more detail on the referral source.  (i.e. name, organization, etc.) 

*Please tell us when to expect copies of your class schedules and class descriptions:  Fax on:  ... JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC ... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ... 2001 2002 2003 2004 2005   

(Note:  Please continue to fax updated class information while participating in this program.  This will keep your membership "active." Thank you.)

Please tell us your thoughts about the CEP Program, what you like/don't like:

Other comments, suggestions, questions?

Please "click" the following to complete the partnership agreement:

* I certify that I am a Childbirth Educator, RN, DONA, midwife or other healthcare professional who is actively involved in directing, coordinating and/or teaching at least 4 courses per year.

*  I certify that I will use and/or will encourage others within my organization to use the Family4Life LaborGear Bag and/or brochures I receive for in-class demonstrations, and not for personal use outside of my involvement in childbirth classes and/or labor and delivery.

*  I certify that I will fax copies of my organization's birthing/labor & delivery related class schedules and class descriptions while participating in this program.

*  I realize that if I decide not to use the Family4Life LaborGear Bag for in-class demonstrations or for labor and delivery related experiences, for whatever reason, I will notify Family4Life.

*  I realize that I will be notified within 10 business days via email  if approved.  If I do not receive an email notification, then I may resubmit my registration within 30 days.    

Thank you.  Please press submit when you are ready to send us your registration form.  We will review your application and contact you within 10 business days.  We look forward to a very rewarding partnership and more importantly to building a lasting relationship with you.

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