DOSA NPO # 2010/011709/08
Postnet Suite # 259
Private bag X31
Saxonwold
2132
T: 011 791 0286
F: 086 654 7003
E:
W: http://www.doula.org.za
Membership Application Form
PERSONAL INFORMATION:Full name:
Tel: / Cell:
Email: / Website:
Physical Address: / Postal Address:
Identity/Passport number: / Date of birth:
EDUCATION:
Doula qualifications:
Institutions/Trainers:
Date of qualifications:
Any additional qualifications/skills:
Please specify what type of doula you are and length of time actively involved:
Pre-partum doula / Birthing doula / Post-partum doula
Part-time doula / Full-time doula / Occasional lay doula
Other: / Details:
What geographical area would you prefer to work in?
Number of births that you have attended: (please mark appropriate selection)
0-5 / 6-20 / 21-50 / 51+
DOSA NPO # 2010/011709/08 - Postnet Suite # 259, Private bag X31, Saxonwold, 2132
T: 011 791 0286 - F: 086 654 7003 - E: - W: http://www.doula.org.za
DOSA NPO # 2010/011709/08
Postnet Suite # 259
Private bag X31
Saxonwold
2132
T: 011 791 0286
F: 086 654 7003
E:
W: http://www.doula.org.za
BIRTH STORIES:We ask you to share your personal birthing/breastfeeding experience with us in order that, once you are in our database, we can effectively match you with appropriate clients who may require your specific knowledge. I.e. If perhaps you have a child with special needs? Did you have a difficult, but ultimately successful, breastfeeding experience? Etc. Please use a separate piece of paper and attach your birth story as an addendum hereto. Thank you.
Signature: / Date:
OFFICE USE:
Membership number:
Commencement/renewal date:
Documents submitted: ID ___ - Qualifications ___ - Birth stories ___ - Proof of payment ___
Application checked by:
Additional comments:
DOSA NPO # 2010/011709/08 - Postnet Suite # 259, Private bag X31, Saxonwold, 2132
T: 011 791 0286 - F: 086 654 7003 - E: - W: http://www.doula.org.za
DOSA NPO # 2010/011709/08
Postnet Suite # 259
Private bag X31
Saxonwold
2132
T: 011 791 0286
F: 086 654 7003
E:
W: http://www.doula.org.za
DOSA NPO # 2010/011709/08 - Postnet Suite # 259, Private bag X31, Saxonwold, 2132
T: 011 791 0286 - F: 086 654 7003 - E: - W: http://www.doula.org.za