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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Gender

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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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