Please print and fill out the application form below and send it with a letter of introduction and $150 nonrefundable deposit for the Assistant and Advanced Workshops, or $100 nonrefundable deposit* for the NRP workshop, to the following address:
The Farm Midwifery Workshop Program
P.O. Box 217
Summertown, TN 38483
application-form-2017e WORD DOC
When we receive your application and deposit, we will send you a confirmation letter which will include a curriculum/schedule for the workshop, a book list, and a list of things you need to bring.
The non-refundable deposit goes towards the workshop fee.
*If the workshop becomes full (before you have been accepted) we will return your deposit. The deposit is only non-refundable if you cancel after being accepted to the workshop.
The remaining fees should be paid one month before the workshop starts unless you make different arrangements with our office.
Please send payment in Money Orders or Certified checks in U.S. funds.
Make checks payable to The Farm Midwifery Workshop.
To Pay by Credit Card:*
If you would like to make a payment with a credit card, please e-mail us at firstname.lastname@example.org with the amount you would like to pay. We will then e-mail you an electronic invoice through PayPal, which can be paid by most major credit/debit cards. There is a 4% additional fee for all credit card transactions.
If you pay the balance of your workshop fee (entire amount after deposit, but doesn’t have to include housing or other fees) with a money order or certified check, you can receive a discount of:
$75 for the Assistant and Advanced workshops
$25 for the Neonatal Resuscitation workshop.
-in order to receive the discount, you must pay your workshop balance by money order or certified check, and we must receive it one month before the start of your workshop-
If you have any questions please contact us at:
Our workshops typically fill 4-6 months in advance (with the exception of the NRP workshops).
If a workshop is full, you can be added to our waiting list for any of the workshops.
Please contact us at email@example.com with your name, address, phone number, e-mail, and which workshop you are interested in.
Midwifery Workshop Application Form (Please check the workshop you plan to attend)
Midwifery Assistant Workshop (Date) ________________ $1350
Neonatal Resuscitation – (Date)_____________ $350
Advanced Midwifery Workshop – (August 6-11, 2017)_____________ $1500
See information above about our cash discount.
Occasionally we are able to offer additional, optional classes, such as Watsu, which will have an additional fee, paid at signup during the workshop.
Name_______________________________________________________________ Age _____________ (20 and up please)
City _______________________________________ State __________ Zip ____________
Phone # _______________________________ Cell Phone #____________________________
Email Address _________________________________________________________________
Level of education _______
I am a □ Doula □ Midwife □ Nurse □ MD □ other_________________
I have my Cardio-Pulmonary Resuscitation Certificate: Yes___No___ Date received: ________
Along with your application and deposit, please send a short letter of introduction on a separate page about why you are interested in midwifery and describe any experience you have related to midwifery (this letter is important in order to process your application). Please send us a photo of yourself. This helps us to match names with faces and get to know you.
We also provide photos to our shuttle drivers which aids them during pickup.
I plan to use the shuttle ($90 each way) to and from the Nashville Airport.
Shuttles booked outside our normal shuttle schedule are charged $115.
You will receive our shuttle schedule with your confirmation letter.
$90 one way __________$180 both ways _________
Do not make plane reservations until you receive confirmation that you are in the workshop.
Accommodations for Workshops: rates apply to workshop nights & 1 night before or after.
Please check what accommodations you want.
Community Center Dorm Bed: □ $20/night/student
Private room: □ $35/night/student
Cabins if available: □ $450 – $700/week: contact us for details about available cabins
Clinic Rustic Cabin □ ($450/week) Read under Accommodations about Clinic Rustic Cabin
Accommodation Reservations are not complete until you have received your confirmation letter and we have received your arrival and departure information.
Do you have any pet allergies? Y / N _________
Please list any food allergies you have: ___________________________________
For Coffee and Tea (served throughout the day) you prefer: (please check box)
□ Half & Half □ Soy □ Almond □ Coconut
I have enclosed a total of __________ to cover the deposit ____________, shuttle________, private room___________, books_________.
*to pay by credit card, request an electronic PayPal invoice and see above information.
I agree to pay the balance of __________ 30 days before the start of the workshop.