Midwives Model of Care Supporter

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Your PayPal order was successful, and your payment has been sent to MANA. In order to complete your registration, please fill out the following form and submit it to the MANA membership chair. 

If you joined as a Midwife, Voting member, be sure and check the appropriate box if you want your referral information listed on our the Mothers Naturally website. Also, please double-check the information you fill in this form in the fields with the pink colored background, as that is what will be listed on the referral page.

If you forget your username and password to access the MANA Members Only area, they are available by logging into your PayPal account and viewing your subscription details within the history log.

I joined as a Midwife/voting member, and I want to be listed on the Mothers Naturally referral page: Yes  No
First Name*
Last Name*
Credential(s) to listed on Mothers Naturally referral page (please use abbreviations)
Name on PayPal account used to pay for this membership (especially important to fill this out if your PayPal account is in someone else's name or your business name)*
Street Address*
City*
State/Province*
Postal Code*
Country
Home Phone Number
Work Phone Number (if you will be listed on the Mothers Naturally website, this is the phone number which will show there)
E-mail*
Web page URL
Check "yes" to save postage and printing and read your MANA News online in the Members Only area* Yes, I will read my MANA Newsletter on-line  
No, please snail mail me a MANA News
Check "yes" if you would like us to snail mail you a MANA Membership card. Check "no" if you have no need of a MANA membership card* Yes, I would like a MANA membership card  
No, I do not need a MANA membership card

*Required information

I am a (check all that apply):
 CPM  CNM  CM  Direct-entry Midwife
 Student/Apprentice Other: 

As a Midwife I am:

Licensed

 Yes  No
 Certified Yes  No

If licensed or certified, in what State or Province? 

I would like to be entered in any or all of these Sections of MANA in addition to my geographic region (check all you would like to join):
 CPMs (only for CPMs)  International Confederation of Midwives  Midwives of Color (for either midwives or students of color)  Students (only for midwifery students, not for practicing midwives)

I am interested in volunteering for the following committee work: 

My Name and Address Can Be Released For
Research Yes  No
Conferences Yes  No
Products Yes  No

Comments:

  

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