National End of Life Doula Alliance · End-of-Life Doula Trainer Membership Form

Annual Membership Fee

*

$75

Your credit card will be renewed automatically on your sign-up date to ensure your membership for the next year.

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone

*

This will be the one used in the trainer directory

Name of Your Business

*

Email

*

This will be the one used in the trainer directory

Verify Email

*

Website, beginning with http://www.

*

Age Range

*

Gender

*

Race / Ethnicity

*

Check all that apply

Caucasian

African American /Black

Latinx

Native American

Asian

Bi-Racial

Multi-Racial

Other

Prefer not to answer

Education Level

*

Household Income

*

Percentage of Income From Doula-related Work

*

Please list the percentage of your household income that comes from your doula work.

Teaching Specialty

*

Details on the Training Program You Offer Others as Well as Your Credentials

Please describe the training program you offer to other doulas (max of 350 characters) and list your credentials to be included in your directory listing.

Number of Years Teaching Doula Training

*

I would like to be involved with NEDA as a volunteer:

Please check all that apply

I have interpersonal/leadership skills

I have organizational skills

I have media/publicity skills

I have writing skills

I have public speaking skills

I have technological skills (i.e., website or database maintenance, etc.)

I have networking skills (building bridges with individuals and other orgs.)

I have fundraising/development skills

I have administrative skills

NEDA End-of-Life Doula Trainer Directory

*

I acknowledge that by agreeing to have my contact information listed on the NEDA Online Directory I may be contacted by individuals, companies, or groups not associated with NEDA. My contact information will be public and cannot be controlled by NEDA.

Yes, I want to be included in the website Directory

No, I do not want to be included in the website Directory

Permission to be Added to NEDA Email List

*

NEDA sends out a monthly newsletter as well as webinar announcements to members only. You always have the option to unsubscribe to the emails at any time.

Yes, I want to receive the monthly newsletters and member-only webinar announcements (including zoom links and recordings)

No, I do not want to receive the monthly newsletters and member-only webinar announcements

NEDA Regional Group Contact Sharing

*

Yes, I give permission to share my email address with other NEDA members interested in forming regional groups

No, I do not give permission to share my email address with other NEDA members interested in forming regional groups

Upload Head Shot Photo

*

Please use professional head shot, if possible.

Directory Agreement

*

By clicking the box below, I am indicating that I understand and accept the following terms: 1) Inclusion of my information on the website directory does not constitute endorsement by NEDA or my training organization, if I have one. 2) I am fully responsible for my own contracts, promotion, and interaction with the public. 3) I have read and agree to honor the NEDA Code of Ethics, Conduct, and Scope of Practice. 4) I understand that my listing on the website directory will only be included as long as I am an active member of NEDA (renew each year).

Yes, I agree