Contact Information

Name

Street Address

City, State, Zip Code

Home Phone

Work Phone

Cell Phone

Fax

E-Mail Address

Website address

___ Yes        ___ No

Please list me on idahomidwives.org “Find a Midwife” page.

Who are you in Midwifery?

Please check all which apply.

___ CPM

___ DEM

___ Doula/CBE

___ CNM

___ Student

___ Other

Membership type and payment:  Current membership is January 1 – December 31.

___ Voting member, open to midwives and student midwives

$35 per year

___ Non-voting member

$15 per year

Payment should be made out to Idaho Midwifery Council and may be submitted by:

___ Check

___ Money Order

___ Paypal, by online payment

Submit application

Submit your completed application with payment:

___ by mail to Kendra Scarlett, 388 Coyote Way, Bonners Ferry, ID  83805

___ by email to Kendra Scarlett at zfreen@nidaho.net.