MEMBERSHIP APP 2022

Central Coast Childbirth Network Membership Application

Thoroughly review your application before completing with payment. updated 1/12/2022
Thank you for your interest in CCCN Membership!
- NEW Applicants
  - Complete all sections of the application below, it will be reviewed and if approved, your payment will be processed and you will gain access to membership benefits. During our review, missing or incomplete fields may result in delays or a denial of membership.
- RENEWING Members
  - If we have your most current contact and listing info, only fill out the red asterisk marked required sections + payment info.
  - If you have changes, fill out all sections of the application.
All payment info is secured by PayPal and will only be authorized if your application is approved. Allow up to 15 business days to process applications.

Questions? Zabrina@centralcoastcn.org or (805) CCC-N926
Are you 18+ years old or a Legal Adult? *
Applicant's CCCN Member Status *

New (first-time applicant) --> complete full application below Renewing NO CHANGES I've reviewed my past invoice and/or my info on the CCCN website and confirm it's accurate. ---> complete Membership Selections, skip to the bottom to sign and add payment to complete Renewing WITH CHANGES I have changes in my info or CCCN website listing --> complete full application below Re-Applicant (1+ year expired, or previously denied) ---> complete full application below

Membership Selections- Choose 1 type including primary category *

Active 1 Year individual or business

$ 40.00 Primary Catagory

Passive 1 Year individual or business

$ 50.00 Primary Catagory

Group or Nonprofit 1 Year business, organization, or network

$ 110.00 Primary Catagory

Additional Listed Categories Select checkbox for drop-down options. Each adtl. category is $5 each (mark QTY)

$ 5.00

	Additional Category	Qty.
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Item subtotal: $ 0.00

Enter coupon

Total

$ 0.00

Contact and Professional Membership Listing

The following is required for NEW Active, Passive, and Group/Nonprofit Members OR Renewing Members needing to make changes.
Contact info is private unless otherwise mentioned. Professional Membership Listing info provided may be published on the CCCN website and CCCN directory unless otherwise requested.

PUBLISH my Professional Membership Listing information DO NOT publish any info about me/my business
This membership represents a(n)...

business/group/organization/practice/entity. Can be Active, Passive or Group 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

This section is for billing and Primary Contact purposes ONLY. Any "Optional" fields in this section submitted with blanks are assumed intentional. If fields necessary for billing are blank, we cannot approve the application.
Primary Contact Name

First Name Last Name
Primary Contact's Pronouns (optional)
*if pronouns included, should they be inlcuded PUBLICALLY on your Professional Membership Listing?

Yes No
Name of business, group, organization, practice, or entity applying for membership
if individual use the Primary Contact's name
*Non-Profits only, EIN #
Primary Contact's role/title within business, group, organization, practice, or entity applying for membership
example: Owner, Director, Employee, Partner, Self
Primary Contact E-mail
example@example.com
Primary Contact Number

Area Code Phone Number
alt. Contact Number (optional)

Area Code Phone Number
Preferred method of contact

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

Yes No
Address for Billing

Street Address

Street Address Line 2

City State

Zip Code Country
We enjoy celebrating birth! Share your birthday with us. (optional)

Month Day Year
Professional Membership Listing

ONLY include info you want shared PUBLICLY, any blanks below are assumed intentional. All fields in this section are optional, but if you want info shared--include it!
Listed Name (PUBLICLY LISTED)
individual, business, group, organization, practice, entity, or trade name such as, “Chelsea Sanders”, “SLO Aromatherapy Collective”, “Chelsea the Kindred Aromatherapist”
Credentials (PUBLICLY LISTED)
degrees, certifications, licensees or qualifications to follow your Listed Name.
Address (PUBLICLY LISTED)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Number (PUBLICLY LISTED)
Email (PUBLICLY LISTED)
example@example.com
Website (PUBLICLY LISTED)
Hyperlink for Instagram account (PUBLICLY LISTED)
Hyperlink for Facebook Account (PUBLICLY LISTED)
Hyperlink for LinkedIn Account (PUBLICLY LISTED)
Hyperlink for any other social media account (PUBLICLY LISTED)
Spotify, YouTube etc. *other options provided may be added at our discretion due to limited space on listing profile
Would you like to add a member to member discount?

Yes. No.
If Yes, please explain what type of discount. (PUBLICLY LISTED to CCCN Members Only)
For example: Free consult, 10% off etc.
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
Do you offer services in additional languages? (PUBLICLY LISTED)

Spanish Mixteco Other
Please attach 1 photo for the member directory listing. (PUBLICLY LISTED)

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Cancel of
In 1-3 sentences, include a short bio or mission statement that will go with your photo and professional info. (PUBLICLY LISTED)
The CCCN upholds diversity, equity and inclusion with language and practices. Consider using inclusive and affirming language. Example: parent, co-parents, birthing person, families, family, individual, person, and people.
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, Denas Salas of Dena Salas 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. *

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Central Coast Childbirth Network Membership Application

Contact and Professional Membership Listing

Contact Information

Professional Membership Listing