Santa Rosa Registration


	Print and Mail Registration Form (or copy and paste it into a document for printing) Name_____________________________________ ___________________________________ Please print as you want your name to appear on your name tag and certificate Address___________________________________ City,State,zip_______________________________________ Phone #s_(_____)___________________________ email_____________________________________ Credit card number_______________________________ Profession_________________________________ Credit card name______ Exp date ______ Code ______ Are you a CBE__, LLLI Leader__, EMT__, trained in... acupuncture__ acupressure__, midwifery__, nursing__, medicine__, massage__, aromatherapy__ other________? You need not be to attend! # of children__ # vaginal births __ # cesarean births__ # vbacs __ (You need not have given birth to be a doula!) Please include a separate sheet of paper that discusses how you came to be interested in this workshop and your experience with birth. If you have given birth, please tell me what you think I would need to know about your experience. Write as little or as much as you want. Please circle dates you wish to attend: July 23 (Intro), 24 and 25 (workshop), 2010 September 17 (Intro), 18 and 19 (workshop), 2010 November 5 (Intro), 6 and 7 (workshop), 2010 ____Intro and Doula Workshop – $500 Registration includes 3 day program, handouts, snacks and certificate of completion for childbirth and doula workshop. ____Doula Workshop only - $375 Registration includes 2 day workshop, handouts, snacks and certificate of completion for doula workshop. ____Intro only – $125 Registration includes 1 day workshop, handouts, snacks and certificate of completion for childbirth education. Your registration in this workshop indicates agreement to all stipulations in this brochure. ____I would be interested in talking with you about hosting an out-of-town participant at my home during the workshop. PLEASE PRINT OUT AND MAIL THIS FORM IN WITH YOUR PAYMENT TO RESERVE YOUR SPACE. Send to: Connie Sultana, 933 Hacienda Circle, Rohnert Park, CA 94928-6005. Make check payable to The Women's Health and Birth Center.

© 2008 Connie Sultana Doula

Doula Workshops


	Registration and Confirmation Workshop attendance is limited to 12 people. Please call or email for directions. You will receive a phone call or email confirmation that your space is reserved. Attendance at this workshop is a privilege, not a right. The instructor reserves the right to deny participation in the workshop at any time, in which case a refund would be provided. Prices and Payment Plans $375 - $500...See below. A non-refundable $100 deposit can be accepted, with payment completed at workshop. Make check payable to The Women's Health and Birth Center. Extended payment plans and credit cards - contact Connie at 707 588-8026, 7:30am - 10pm. Workshop Location Women's Health and Birth Center, 584 Summerfield Road, Santa Rosa, CA. Cancellations Because of limited registration, refund requests will be honored when more than 2 weeks before the workshop are allowed. You may find a replacement for yourself at the workshop. Refund requests postmarked before that date must be sent in writing to Connie Sultana at the address below or via email to conniesultana@sbcglobal.net. A $100 materials and processing fee will be retained for cancellations or postponements immediately before or during the workshop. Workshop Cancellation There needs to be a minimum of 6 paid registrants in the workshop. If there are less, the workshop will be postponed and all money will be returned. Further information Connie Sultana at (707) 588-8026 PST, conniesultana@sbcglobal.net