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Join the Colorado Alliance of Independent Midwives

First Name __________________________

Last Name __________________________

Address ____________________________

City _______________________________

State ______________________________

Zip Code ___________________________

Home Phone ________________________

Work Phone ________________________

E-Mail ____________________________

Please circle one:

I would prefer to receive the newsletter by: E-mail / Snail Mail.

Yes / No - I am interested in a payment plan or a reduced fee membership, explanation is enclosed.

Yes / No - I am interested in volunteering for committee work ( please list areas of interest):__________________________________________________________

Yes /No - My name and address may be released for persons seeking a midwife persons doing research.

*OPTIONAL- I am a:

Independent Midwife Apprentice CNM Student

Consumer / Parent CBE Doula Other Healthcare Provider

Please make checks payable to:
C-AIM
P.O. Box 40576
Denver, CO 80204-9998

Annual Membership Fee:  $50.00

NOTE: You must print this form or cut and paste it into an email, fill it out, and mail it to the address above.  To print simply press the Print button on your browser.

For more information, contact us via email at homebirthcolorado@yahoo.com

 
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