CCCN MEMBERSHIP APPLICATION
Thank you for your interest in becoming a Central Coast Childbirth Network Member! After completing the application below, your membership listing draft will be created. We will forward to you for review and your listing will go live on our website once the membership listing is approved AND payment has been submitted. Please allow up to 5-7 business days for approval and payment request. Membership dues and payment instructions will be available upon approval. For questions please contact Zabrina@centralcoastcn.org or (805) CCC-N926 APPLICATION Updated 12/28/2020
Please Choose 1 yearly membership. (+ADDITIONAL LISTINGS MAY APPLY.)
INDIVIDUAL ACTIVE $35/YR
NON-PROFIT $35/YR
PASSIVE $45/YR
GROUP $100/YR
All Members
The following information is required for Active, Passive, and Group Members. Contact information is private unless otherwise mentioned. Professional Membership Listing information provided will be listed publicly on the CCCN website and CCCN printed directory unless you request it not to be used publicly, by checking the box below:
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Please DO NOT publish my Professional Membership Listing information.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 Group
an 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)
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Name
*
First Name
Last Name
If you would like to, please include any personal pronouns.
Can we include your pronouns with your listing?
Yes
No
Business/group/organization/practice/entity name
*
*Non-Profits only. Please provide you EIN Number.
Role/Title
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Cell Number (if different then phone number):
-
Area Code
Phone Number
E-mail
*
Preferred method of contact: Phone, or Email
Phone
Email
Can we reach you via text for updates and membership reminders?
Yes
No
Membership Listing
(ONLY include information that you want listed publicly)
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
City
State / 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 Obispo
North SLO County
South SLO County
ALL of SLO County
Santa Maria
North Santa Barbra County: Buellton, Lompoc, Solvang, Santa Maria
Other
1 listing category is included in membership. Please choose 1 listing category from the options below. (PUBLICLY LISTED)
If you would like to be added to additional categories check all that apply. * Each additional listing will be charged at $5, up to 5 max per profession. (PUBLICLY LISTED)
Acupuncture
Baby & Toddler Programs
Babywearing
Birth Center
Childbirth Education
Childcare
Chiropractic Care
Doulas
Fitness & Nutrition
Infant & Child Sleep Consulting
Lactation support
Massage Therapy & Bodywork
Mental Health Professionals
Midwifery
Obstetrics
Parenting Education & Support
Pediatric Care
Photography & videography
Placenta Encapsulation
Retail
Infertility
Bereavement
Support Group/Program
Non-Profit
Other
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)
Yes
No
If yes, please explain what type of discount. For example: Free consult, 10% off etc. (PUBLICLY LISTED)
Please attach 1 photo for the member directory listing. (PUBLICLY LISTED)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you offer services in another language? (PUBLICLY LISTED)
Spanish
Mixteco
Other
Do you have additional training or education in the LGBTQ+ community?
Yes
No
If you do not, would you be interested in a discounted course for education in the LGBTQ+ community?
Yes
No
How did you hear about CCCN?
Facebook
Instagram
Website
Internet search
Flyer/Brochure
Referral
Other
As part of your membership, Karla Wenger of Karla Wenger photography has donated her services for 1 professional headshot for members ONLY.
Yes, I am interested. Contact hello@karlawengerphotography.com
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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