Register Now

Fill out the Application Form below and send it with a deposit of $75.00, a self photo and a letter of introduction about yourself and what you do, especially your experience in regard to helping women and babies. The $75 deposit goes toward the total workshop fee.

The Farm Midwifery Workshop Program
P.O. Box 217
Summertown, TN 38483

Application-Form-for_2017 PDF

Application-Form-for_2017 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. If a workshop is full, you can be added to our waiting list for any of the workshops.

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 midwives@midwiferyworkshops.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.

If you have any questions please contact us at:
midwives@midwiferyworkshops.org
931-964-2257

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Please contact us at midwives@midwiferyworkshops.org with your name, address, phone number, e-mail, and which workshop you are interested in.

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Application Form

Fill out the Application Form below and send it with a deposit of $75.00, a self photo and a letter of introduction about yourself and what you do, especially your experience in regard to helping women and babies. The $75 deposit goes toward the total workshop fee.

I plan to attend the: check the box and fill in the date

□ Midwifery Assistant Workshop $1,375  Date: ________________________

□ Advanced Midwifery Workshop $1,500  Date: August 6-12, 2017

□ Neonatal Resuscitation Class $350     Date: ________________________

Full Name_______________________________________ Age____(20 and over please)

Address________________________________________________________________City____________________

State__________________ Zip+ four_____________________

Phone:__________________CellPhone:___________________e-mail: _____________________

I am a □Doula  □Midwife  □Nurse  □MD  □ other_________________

Please send your application with, deposit and a short letter of introduction on a separate page why you are interested in midwifery and what your experience is related to midwifery so far. Please send us a photo of yourself. This helps us to match names with faces and get to know you.

 

Accommodations for Workshops: rates apply to workshop nights & 1 night before or after.

Please check what accommodations you want.

Community Center Dorm Bed: □  $25/night/student

Private room: □ $40/night/student,

Cabins if available: □ $550 – $700/week: contact us for details about available cabins

 

I have my Cardio-Pulmonary Resuscitation Certificate Y / N (CPR)___________

Have you completed any colege level anatomy or physiology? Y/N __________

 

Do you have any pet allergies? Y / N _________

Please list any food allergies or sensitivites 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 _________.

Allocated as follows: Workshop Deposit:_______. Shuttle:________. Accommodations:________. Books:_______.

*to pay by credit card, e-mail us midwives@midwiferyworkshops.org for a PayPal invoice

I agree to pay the balance 30 days before the workshop starts.

 

Signature_________________________________ Date______________

To contact us:  call (931) 964-2257 on Tues, Thurs, or Fri between 10:00am and 2:00pm Central Standard Time or email midwives@midwiferyworkshops.org

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