Find a Birthing Professional

Enrollment Form

Enrollment Form

Please fill out the form completely and accurately.

Full Name (*)

Please let us know your name.
Email (*)

Please let us know your email address.
Mailing Address (*)

We will use this address to send materials, please ensure it is accurate.

City (*)

Please tell us what city you live in.
State (*)

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Zip (*)

Please fill in your zip or postal code.
Home Phone (*)

Cell Phone

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Date of Birth (*)

Please fill in your Date of Birth.

Background & Education Information

Race (*)

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We collect demographic information for informational & grant seeking purposes only.

This will not affect enrollment.

Education Level (*)

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Employment Status (*)

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Other Credentials

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Do you have any other credentials, medical affiliations or relevant qualifications?

If so, please describe:

Anticipated Start Date (*)

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Program Preferences

What program do you plan to enroll in? (*)

Please Make A Program Choice (prices listed do not include workshop fees which are required for certification)

Tuition Preference

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How did you find out about BWI?

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What makes BWI the best fit for you personally? (*)

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Workshop Preferences

Is there an upcoming workshop that you are planning to attend? (*)

Invalid Input Please let us know if there is a workshop you plan on attending already.

Are you willing to travel in order to complete the workshop reqirement?

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Are you interested in hosting a workshop?

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How would you prefer to be contacted? (*)

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