Membership Application

Please Note: The Flagstaff and Arizona Birth Networks endorse the Mother-Friendly Childbirth Initiative (MFCI) created by the Coalition for Improving Maternity Services (CIMS) and requires that ALL members endorse the MFCI. Please read the MFCI document, and then visit motherfriendly.org to endorse the initiative, must be completed before submitting your Flagstaff Birth Network Member Application.

Member Information

    First Name:
    Last Name:
    Business/Organization Name:
    Address:
    City:
    State:
    Zipcode:
    Home Ph:
    Mobile:
    Work:
    Which number would you prefer to advertise on website and in print?
    E-Mail Address:
    Confirm E-Mail Address:
    Website:
    Primary Geographic Area Served:
    Other:

Referral Listing Category*

    Breastfeeding Support
    Childbirth Educator
    Chiropractor
    Doctor (specialty):
    Doula - Birth
    Doula - Post Partum
    Massage Therapist (type):
    Retail Store
    Other (please list):
*One category for Business or Non-Profit Membership, up to four categories for Corporate Membership. Additional listings $25.00 per year.

Qualifications (degrees/training/certifications):

Brief description of services offered, community served, etc:

*For corporate memberships with more than one partner/employee, please complete the above information for each individual to be listed*

Level of Involvement:

Please send me information on volunteer opportunities with the Flagstaff Birth Network. I am interested in the following:

    Serving on a Committee
    Serving on the Board of Directors
    Serving on the Advisory Board
    Speaking at an event
    Volunteering at an event
    Other/Unsure:

I am not interested in volunteering at this time.

Newsletter Subscription:

I would like to receive my copy of Arizona Birth Connection by:

For Non-Profit and Corporate Members - number of subscriptions you wish to receive (all sent to above address):

Desired Membership Level:

    Personal Membership - $25.00
    Business Membership - $50.00
    Non-Profit Organization Membership - $60.00
    Corporate Membership - $100.00
    (Number of listings requested):
    Benefactor Membership - $200.00
    Additional Listings - $25.00 each

Total Payment:

Payment Method

    Check #
    Money Order

Make all checks and money orders payable to Arizona Birth Network - Flagstaff Chapter. There will be a $25.00 NSF fee for returned checks. If funds are sent via paypal, payment must be completed and the endorsed MCFI Agreement Letter must be submitted before your application will be processed. Please mail payments to: Flagstaff Birth Network, PO Box: 31378, Flagstaff, AZ 86003-1378. Call 928-224-4366 with questions/inquiries.

I endorse the Mother-Friendly Childbirth Initiative {visit motherfriendly.org right now (will open in new window)}.

Additional Message: