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Membership Application Form
and Referral Information Update
Download this page and mail it to:
Stacey Scarborough
4794 Winona Ave.
San Diego, CA 92115
APPLICATION/Renewal form to be part of the Beautiful Beginnings Referral List:
| Name: |
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| Address: |
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| Phone Number: |
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| Cell Number: |
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| Email / Website Address: |
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| Background: |
Brief summary of your training, licenses, degrees, certifications, etc. You may also submit a resume if you have one. |
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| Specialties: |
Please circle all that apply to you. |
Labor Doula Postpartum Doula Childbirth Educator Lactation educator/CLC
Fitness instructor Yoga instructor Massage Therapist Acupuncturist
Hypnosis doula Relaxation therapist HHP/Chiropractor |
| Speak other languages? |
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| Organizations you belong to: |
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| Volunteer work: |
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| Availability as a doula: |
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| Preferences: |
(ie: night time work, home births, un-medicated only, epidural/un-medicated ok, breastfeeding only, high risk, etc.) |
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| Any type of client/experience that you don't feel comfortable supporting? |
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| Your Fee: |
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| Philosophy |
Personal beliefs, goals, etc. Please state what your feelings are concerning pregnancy and postpartum period, and why you think a doula/your service is so important for this phase. Please place in paranthesis exactly what you'd like your bio say for you. |
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Once you complete this form, you can send it along with your fee to Stacey Scarborough at the above address.
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