Please answer the following questions about your outside activities that might be related to Lamaze International, its programs, or the field of childbirth education. Overlapping interests frequently arise in nonprofit organizations and are normal. It is a reflection that dedicated and well-qualified individuals often play multiple roles within a professional field. The key is to be aware of the possibility for actual as well as perceived conflicts and to be prepared to manage them in a fair and open manner. In responding to these questions, please note that a “yes” answer does not automatically indicate that the relationship or transaction was inappropriate. If a question is not applicable, please enter N/A in the response field

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* 1. Please list the companies and other places where you perform paid work (employers, commercial companies, research institutions, government agencies, etc.).

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* 2. Please list the organizations and other places where you volunteer or otherwise perform unpaid work as an officer, director, committee member, etc.

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* 3. Do you, either personally or through a related business entity, conduct business with Lamaze International (e.g., as a paid Lamaze Workshop Instructor, Lamaze Program Trainer, etc.), or do you have any connection with a vendor that is doing business with Lamaze International?

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* 4. If yes, please explain. If no, please type “N/A”

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* 5. If any of your family members or business associates have a connection with Lamaze International or the field of childbirth education similar to the questions asked about you above, then please describe those connections here.

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* 6. Please list any other information that you think might be helpful for Lamaze International to know about you, your family members, and your business associates.

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* 7. Please indicate any roles, committees, or councils in which you currently serve for Lamaze International.

By submitting this form, I acknowledge that I have received, read, and understood the Lamaze International policies listed below. I hereby certify that I understand and agree to comply with the policies.

I further acknowledge that I am responsible for complying with all Lamaze policies as they may be updated from time to time, including Lamaze policies not referred to below.

I acknowledge that I have read the Lamaze International Conflict of Interest Policy and Disclosure Form. I do not have any undisclosed actual, apparent, or potential conflicts of interest which are not listed in this Disclosure Statement and agree to abide by the Conflict of Interest Policy. I understand that it is my responsibility to inform Lamaze in writing of any change in circumstances relating to the Conflict of Interest Policy. I hereby certify that I have read, understood, and agreed to the Conflict of Interest Policy and that the information given in this statement is complete and accurate to the best of my knowledge.

In the event that any matter comes before the Corporation’s Board of Directors or any committee of which I am a member involving any matter in which I or a member of my immediate family have a substantial financial interest (by way of ownership, employment, or otherwise), or any transaction with any entity in which I act as a director, partner, trustee, or officer, I shall notify the Board of Directors or the appropriate committee, as the case may be, of the existence and extent of such interest or capacity, and I shall refrain from voting and from using my personal influences thereon. I shall, of course, make available to the other members of the Board or committee, as the case may be, any pertinent information in my possession with respect to such matter that may be properly disclosed.

I acknowledge that I have read the Lamaze International Advertising Standards. I understand that no advertising can be included in professional or consumer publications that contradict or do not support the mission of Lamaze International; and I agree that as a planner/presenter of Continuing Education provided for Lamaze Contact Hours, I will not accept advertising or promotions that may violate the Lamaze International Advertising Standards.

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* 8. Electronic Signature

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* 9. Enter Date

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