Region

Number______
Midwives Alliance of Pennsylvania Membership Form
Help us put PA midwives on the MAP!

Name________________________________________________________________________

Mailing Address________________________________________________________________

County____________________________

Home Phone_______________________ Work/Cell Phone________________________

E-mail________________________________________________________________________

Practice Name______________________________ Web page________________________

License or credential information (if

applicable)___________________________________________

Issuing Organization ______________________________________________________________

Lic. or Cert. # ________________________________ Issue Date Exp. Date

______________

If you are a midwife, what area do you serve? Included key cities, towns, and
counties:
_____________________________________________________________________________

If you are a consumer or other practitioner, please describe the services you
offer/special skills:
_____________________________________________________________________________

I (circle one) do do not want to be listed on the MAP Website.

If you do wish to be listed on the MAP website, please state the services that you
wish to have included in your member listing:
___________________________________________________

_____________________________________________________________________________

I am joining as a:
o CPM, LM, DEM or CNM (voting), $50 o Students, Apprentice Midwives
(voting), $35
o Supporting Members (non-voting), $30 o Special Circumstance (financial
hardship) $__
I am enclosing an additional donation of $ _______to further support MAP’s mission
and purpose.

Please select those committees you are willing to participate on (you may check
more than one):
o Membership & Fundraising o Legislation & Lobbying
o Community Outreach & Education o Administration/Organizational
Development
o Electoral/Campaign Work o Practice Guidelines/Peer Review

Are you interested in serving as a regional representative and/or committee

chairperson?____________
What is your preferred method of voting? ______Online Voting, ______Written Ballot

Thank you for your involvement and support!

Please make checks payable to Midwives Alliance of
Pennsylvania and send to:
MAP c/o Lisa Beherec
111 B Cooper St
Spring Mills, Pa 16875