Old MEMBERSHIP APPLICATION 2021

CCCN MEMBERSHIP APPLICATION

Thank you for your interest in Central Coast Childbirth Network Membership! NEW applicants: After completing the application below, we review your application and if approved, your membership listing draft will be created, and you will be invoiced. Your listing will go live on our website after the membership is approved AND payment has been received. Please allow up to 15 business days for approval and invoicing. Payment instructions will be on the invoice. RENEWING members: Only fill out the application if you have changes from the year before OR select the checkbox below if you have NO changes to be made and DO NOT FILL OUT the rest of the application. Questions? Contact Zabrina@centralcoastcn.org or (805) CCC-N926 Updated 1/10/2022
Please Choose One:*

New Membership (first-time applicant)Member Renewal- Please keep everything the same. *Please see invoice and membership listing to confirm information prior to checking this box.Member Renewal-I want to make changes to my previous application. Please re-apply by completing application.COUPON CODE

Please Choose 1 membership. (+ADDITIONAL LISTINGS MAY APPLY.)*

Individual Active 1 YearPlease enter a short description.

$40.00 Quantity

Individual Passive 1 YearPlease enter a short description.

$50.00 Quantity

Group or Nonprofit Please enter a short description.

$110.00 Quantity

Primary Membership CatagoryFirst Listing Complimentary

$ Free Category

Additional Listed Catagories

$5.00

	Additional Category	Quantity
Selection 1
Selection 2
Selection 3
Selection 4
Selection 5

Total

$0.00

INDIVIDUAL ACTIVE $40/YRPASSIVE $50/YRGROUP $110/YR
Please enter Coupon Code
Are you 18+ years old or a Legal Adult? *
All Members

The following information is required for Active, Passive, and Group/Nonprofit Members.
Contact information is private unless otherwise mentioned. Professional Membership Listing information provided will be listed publicly on this website and CCCN printed directory unless you request it not to be used publicly.*

Please publish my Professional Membership Listing information.Please DO NOT publish my Professional Membership Listing information.
This membership is to represent...*

a business/group/organization/practice/entity, can be Active, Passive or Groupan individual professional (listing will be under an individual’s name and NOT a business/group/organization/practice/entity name. Can be Active or Passive)
Contact Information

for contact and billing purposes only, this will NOT be the public membership listing information
We enjoy celebrating birth! Share your birthday with us.

MonthDayYear
Name*

First NameLast Name
If you would like to, please include any personal pronouns.
Can we include your pronouns with your listing?

YesNo
Business/group/organization/practice/entity name*
*Non-Profits only. Please provide you EIN Number.
Role/Title*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*

Area CodePhone Number
Cell Number (if different then phone number):

Area CodePhone Number
E-mail*
Preferred method of contact: Phone, or Email

PhoneEmail
Can we reach you via text for updates and membership reminders?

YesNo
Membership Listing

ONLY include information that you want listed PUBLICALLY
Listed name (Individual, Business/group/organization/practice/entity, or trade name such as, “Chelsea Sanders”, “SLO Aromatherapy Collective”, “Chelsea the Whispering Aromatherapist”) (PUBLICLY LISTED)
Credentials (degrees/certifications/Licensees). This will follow your name in the listing. (PUBLICLY LISTED)
Address (PUBLICLY LISTED)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (PUBLICLY LISTED)
Please enter a valid phone number.
Email (PUBLICLY LISTED)
example@example.com
Website (PUBLICLY LISTED)
Hyperlink for Instagram Account you would like to include (PUBLICLY LISTED)
Hyperlink for Facebook Account you would like to include (PUBLICLY LISTED)
Hyperlink for LinkedIn Account you would like to include (PUBLICLY LISTED)
Hyperlink for any other social media account you would like to include (PUBLICLY LISTED)
Service Areas (PUBLICLY LISTED)*

San Luis ObispoNorth SLO CountySouth SLO CountyALL of SLO CountySanta MariaNorth Santa Barbra County: Buellton, Lompoc, Solvang, Santa MariaOther
1 listing category is included in membership. Please choose 1 listing category from the options below. (PUBLICLY LISTED)
1 listing category is included in membership. Please choose your primary category (PUBLICLY LISTED)*
If you would like to be added to additional categories check all that apply. * Each checked box will be an additional listing and will be charged at $5 each.(PUBLICLY LISTED)

AcupunctureBereavement SupportBirth CenterChildbirth EducationChildcareChiropractic CareDoulaFitnessFertility SupportInfant and child feedingMassage therapyMedical PractitionerMental Health & WellnessMidwiferyNutritionParental Support & EducationPelvic Floor Physical TherapyPhotography & VideographyPhysical Therapy & BodyworkPlacenta EncapsulationRetail
In 1-3 sentences, please include a short bio that will go along with your photo/contact info. This could be an Individual and/or business statement. CCCN mission and vision values all families. Consider using inclusive and affirming language. Example: parent, co-parents, families, birthing person, family, person, and people. (PUBLICLY LISTED)
Would you like to add a member to member discount? (PUBLICLY LISTED)

YesNo
If yes, please explain what type of discount. For example: Free consult, 10% off etc. (PUBLICLY LISTED to CCCN Members Only*)
Please attach 1 photo for the member directory listing. (PUBLICLY LISTED)

Cancelof
Do you offer services in another language? (PUBLICLY LISTED)

SpanishMixtecoOther
Do you have additional training or education in the LGBTQ+ community?

YesNo
If you do not, would you be interested in a discounted course for education in the LGBTQ+ community?

YesNo
How did you hear about CCCN?

FacebookInstagramWebsiteInternet searchFlyer/BrochureReferralOther
As part of your membership, Tayler Enerle of Tayler Enerle photography has donated her services for 1 professional headshot for members ONLY.

Yes, I am interested.Not at this time.
ATTESTATION: I have read the CCCN Mission & Vision statement and will adhere to it. I accept that any of my promotional materials must be approved by CCCN prior to use at any CCCN event. (please type your name to agree)

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CCCN MEMBERSHIP APPLICATION

All Members

Contact Information

Membership Listing