MDDC NEW MEMBER APPLICATION

Welcome and thank you for your interest in joining the
Mt Diablo Doula Community (MDDC)!

We are individually practicing doulas who form a professional collective of formally trained and ethically practicing Birth and Postpartum Doulas. We serve families in the San Francisco Greater East Bay Area, sign and abide by the MDDC Mission Statement, MDDC Scope of Practice and offer comradery and support to each other. Because of our compassionate group dynamic and positive standing among the surrounding birth / medical communities, we take great care in aligning ourselves with qualified and like-minded doulas.

As an Active Member of the MDDC, you will be required to abide by the MDDC Mission Statement, Birth Doula role description (if applicable), Postpartum Doula role description (if applicable) and Scope of Practice, which can be found on the MDDC Website.

Before moving forward with this application, please review these to be sure you are a good fit for our doula community.

Submitting this application does not ensure you will be accepted as a member into the MDDC. You will be contacted by our Membership Director with further instructions. It takes a new member an minimum of three months to complete the membership process.

For questions, please email. MDDCMembership@gmail.com.

Date

MonthDayYear

Name

First NameLast Name

E-mail

Phone Number:

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name of Business or Practice:

Type of Business:

Sole PropreitorPartnership/Circle

Website:

Business Facebook Page:

Cities/Counties You Serve:

BIRTH DOULA

Have you completed professional BIRTH DOULA training?

YesNo

With which organization, program or individual did you complete your BIRTH DOULA training and/or mentorship? And when?

What is your BIRTH DOULA certification status?

Currently CertifiedPursuing CertificationNot Currently Certified or ExpiredNot Currently Pursuing Certification or Renewal

If applicable, when does your BIRTH DOULA certificaiton expire?

How long have you been practicing as a BIRTH DOULA?

POSTPARTUM DOULA

Have you completed professional POSTPARTUM DOULA training?

YesNo

With which organization, program or individual did you complete your POSTPARTUM DOULA training and/or mentorship? And when?

What is your POSTPARTUM DOULA certification status?

Currently CertifiedPursuing CertificationNot Currently Certified or ExpiredNot Currently Pursuing Certification or Renewal

If applicable, when does your POSTPARTUM DOULA certificaiton expire?

How long have you been practicing as a POSTPARTUM DOULA?

List any other certifications or licencures; or speciality skills you offer:

If accepted as a member of the MDDC, I will honor the MDDC Mission Statement and Scope of Practice and doula roles as outlined on the MDDC Website:*

Yes, I have reviewed MDDC Mission Statement and Scope of Practice and attest that I meet the professional and personal qualifications to pursue active membership with the MDDC.

Name

First NameLast Name

Date

MonthDayYear

MDDC NEW MEMBER APPLICATION

Contact Information:

Background Information:

Application Agreement: