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The Reset Retreat: For Birth Workers & Maternal Health Advocates
Registration Form
Date
: July 21, 2026 | 11:00AM - 3:00PM
Location: The Orchid Bed and Breakfast:
628 N State St, Jackson, MS 39202
*
1.
First and Last Name
(Required.)
*
2.
Email Address
(Required.)
*
3.
Location Demographics:
(Required.)
State
Zip Code
4.
Organization
*
5.
Which best describes your role? (Select all that apply.)
(Required.)
Maternal Health Advocate
Doula
Midwife
Lactation Professional
Community Health Worker
Nurse
Physician
Social Worker
Mental Health Professional
Public Health Professional
Other (please specify)
*
6.
How many years have you worked in maternal health?
(Required.)
Less than 1 year
1–3 years
4–7 years
8–10 years
More than 10 years
*
7.
What are you hoping to gain from this retreat?
(Select up to three.)
(Required.)
Mental wellness support
Rest and self-care
Stress management tools
Professional development
Inspiration and motivation
Community resources
Other (please specify)
8.
On a scale of 1–5, how would you rate your
current level
of stress or burnout?
1 – Very Low
2 – Low
3 – Moderate
4 – High
5 – Very High
*
9.
Do you follow any of the these dietary restrictions? (Please select all that apply.)
(Required.)
Vegan
Vegetarian
Food Allergy (e.g. gluten free, peanut free)
I do not follow any of these dietary restrictions
Other (please specify)
*
10.
Photographs and video may be taken during the retreat for educational and promotional purposes.
I give Six Dimensions permission to use photos or video that may include me.
(Required.)
Yes
No
*
11.
Agreement: I understand that registration is required to attend. I agree to notify the organizers if I am no longer able to participate so my space may be offered to someone else.
(Required.)
Yes:
No
