MEMBERSHIP APPLICATION

Central Coast Childbirth Network Membership Application

Thoroughly review your application before completing with payment. updated 04/07/2025
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. MEMBERSHIP WILL EXPIRE ONE OR TWO YEARS (depends on which membership you apply for) DURING THE MONTH YOU WERE APPROVED AND PAYMENT RECEIVED

Questions? jasmin@centralcoastcn.org
Are you 18+ years old or a Legal Adult?
Applicant's CCCN Member Status

Membership Selections- Choose 1 type including primary category

CCCN Member 1 Year

individual or business (Business defined as 3 or less employees.)

$50.00 Primary Catagory

CCCN Member 2 Year

individual or business (Business defined as 3 or less employees.)

$95.00 Primary Catagory

Group or Nonprofit 1 Year

Business, organization, or network of 4 or more employees.

$110.00 Primary Catagory

Group or Nonprofit 2 Year

Business, organization, or network of 4 or more employees. 10 % off second year

$209.00 Primary Catagory

Additional Listed Categories

Select checkbox for drop-down options. Each adtl. category is $5 each (mark QTY) * Please add QTY 2 for ALL 2 Year Memberships. *Discount does not apply to additional listed categories.

$5.00

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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.
This membership represents a(n)...
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 NameLast Name
Primary Contact's Pronouns (optional)
*if pronouns included, should they be inlcuded PUBLICALLY on your Professional Membership Listing?
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 CodePhone Number
alt. Contact Number (optional)

Area CodePhone Number
Preferred method of contact
Can we reach you via text for updates and membership reminders?
Address for Billing

Street Address

Street Address Line 2

CityState

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

MonthDayYear
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

CityState / Province

Postal / Zip Code
Contact Number (PUBLICLY LISTED)
Format: (000) 000-0000.
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
Service Areas (PUBLICLY LISTED)

Other
Do you offer services in additional languages? (PUBLICLY LISTED)

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

Cancelof
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?
How did you hear about CCCN?

Other
ATTESTATION: I have read the CCCN Mission, Vision, & Values 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.
Pay with PayPal

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Central Coast Childbirth Network Membership Application

Membership Selections- Choose 1 type including primary category*

Contact and Professional Membership Listing

Contact Information

Professional Membership Listing

Pay with PayPal

Membership Selections- Choose 1 type including primary category