Address:
Phone:
Email:
Date of Training you are signing up for:
Please explain your childbirth & postpartum experiences:
Why would you like to become a postpartum doula?
What do you hope to learn from this training?
Please list any professional affiliations:
How did you hear about this training?
RULES AND CONDITIONS:
*Bysubmitting this registration formyou agree to the following:
I understand that there are no refunds for classes but I can transfer to another course withJodi Krentzman within 12 months of the original course date with approval from Jodi Krentzman.
I understand that I must pay for my training in fullat least 30 daysbefore the training by going to or by contacting the instructor to pay with a check.
I understand that I should not make non-refundable travel reservations until Jodi Krentzman has confirmed the workshop 14 days prior to the course.
I understand that I must be a CAPPA member before I can become certified as a CAPPA Postpartum Doula. (You can obtain membership at
As a participant of this training, I agree to allow Jodi Krentzman/CAPPA to do the following:
1. Publish my name, address, phone number, and email address for the trainee class list & referral list.
2. Take photographs of the training which may include me, as well as allow the trainer and CAPPA to use these photographs for promotional purposes
online and in print.
3. Use quotes from my training evaluations (which I may fill out anonymously) for promotional purposes online and in print.
I understand that I may not record the training workshop (audio or video).
I understand that I may not photograph any PowerPoint slides, training materials, certificates of completion or any other intellectual property belonging to CAPPA or the trainer.
I may take photographs during the training only with the express permission of the trainer and the participants. I may not post any pictures on social media nor email any pictures from the training without express permission of the trainer and the persons in the photograph.
I may not reproduce, publish or distributeany materials in the training manual.
I may not reproduce, publish or distributeany materials from the certification packet, other than for the purpose of fulfilling my certification requirements (i.e. copying the evaluation forms for my clients to fill out)
I may not reproduce, publish, photograph, share, email, or distribute any materials in the training binder (handouts) other than for the purpose of using them for my personal business as a postpartum doula.
I understand that this course is only one step in becoming a CAPPA Certified Postpartum Doula. There are several other steps that must be completed by the student after the training in order to be eligible for certification by CAPPA.
I understand that I must enroll in CAPPA Academy to complete my certification. CAPPA Academy is an online certification component where I can receive step-by-step instructions on completing my certification, download necessary forms for my certification and take the multiple choice and essay exam. I understand I only have access to CAPPA Academy for 1 year.
I understand that I must attend all days of the training. If I miss any portion of the training, I will not receive a certificate of completion and/or Contact Hours.
I understand that due to the intense nature of the class and out of respect for the other students, no babies/children are allowed in the classroom during instruction time. Nursing babies may be brought to mom to nurse during breaks and/or lunch.
I understand that I must be at least 18 years old to get certified as a CAPPAPostpartum Doula
CAPPA Certified Postpartum Doula
The Postpartum Doula:
Assists the new mother, baby and the rest of her family within the first few weeks after the birth of the baby. The postpartum doula may offer the following:
Breastfeeding education & assistance
Newborn care instruction
Household help
Sibling Care
Meal Preparation
Errand Running
Support and Guidance
Parent Education
Local resources
NOTE: Postpartum doulas do NOT offer any form of medical advice for mother or baby. They also do NOT perform clinical tasks on mother or baby. They are also NOT babysitters nor nannies!
During your training you will receive the tools necessary to begin the certification process with CAPPA. For starters, you have chosen to attend the training on the following dates: ______. Each class begins at 8:30 am and ends at 6:00 pm (this may vary depending on circumstances). At the start of class you will be given a curriculum and the training manual.
IMPORTANT!!!! You will also need to become a member of CAPPA. You can do this at . If you are already a CAPPA member, please provide your membership number on your registration form
FEES: The workshop fee is $400.00 and includes the training manual.There are no refunds (unless I cancel the class due to low enrollment), however, should you need to cancel you can apply the fee towards any of my future trainings within twelve (12) months, should a training be available, if not all funds are forfeited. There is a $50 transfer fee. You can pay for your training via paypal at
Initials: ______
Your space is not secured in the above-mentioned training until your deposit and this form is received and you have received a confirmation from me via email or by telephone. Please get those items to me quickly as space may be limited and I don’t want you to miss this opportunity! Also, if the number of required students isn’t met, I reserve the right to cancel class and you will receive notice prior to class date and I will refund all monies paid at that time. I look forward to meeting you and having you in class. Please do not hesitate to call with any questions that you may have.
Sincerely,
Jodi Krentzman, CPD, CLE
Certified Postpartum Doula Trainer, CAPPA
(617) 438-9723
Your signature (by signing you agree to the terms above) ______date:______