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* 1. Name

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* 2. Date

Date / Time

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* 3. Address

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* 4. Phone Number(s)

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* 5. Email Address

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* 6. Hobbies & Interests

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* 7. What has led to your interest in birth doula work?

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* 8. Do you have any previous experience with birth?

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* 9. Do you have children and, if so, what are the story(ies) of their birth(s)?

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* 10. Please acknowledge that you understand a deposit of $400 must be received before registration in the doula course is complete.  Payment may be made through paypal on our website (www.taoshomebirth.com) or by sending a check to Taos Midwifery, PO Box 1946, Ranchos de Taos NM 87557.  If you pay in full before October 1st, you will receive a discounted rate of $750.

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