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End-of-Life Doula Membership Form
Annual Membership Fee
*
$50
Your credit card will be renewed automatically on your sign-up date to ensure your membership for the next year.
Annually
Name
*
First Name
Last Name
Professional Degree / Credential Abbreviations (ie. RN, PhD, JD)
Address
*
Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Phone
*
Geographical Service Area
*
Email
*
Website, beginning with http://www.
Gender
*
select one
Female
Male
Transgender
Non Binary
Age Range
*
select one
18 - 25
26 - 35
36 - 50
51 - 60
60+
Race / Ethnicity
*
Check all that apply
Caucasian
African American /Black
Latina / Latino
Native American
Asian
Bi-Racial
Multi-Racial
Other
Education Level
*
select one
Did not graduate from High School
High School Graduate or GED
Some College
College Degree
Graduate School
Professional Degree
Current Occupation
*
Household Income
*
select one
Less than $10,000
$10,000 - $25,000
$25,000 - $50,000
$50,000 - 100,000
$100,000 - $150,000
Over $150,000
Percentage of Income From Doula-related Work
*
Please list the percentage of your household income that comes from your doula work
Professional Titles
*
Check all that apply
Nurse -- RN
Nurse -- LPN
Nursing Administrator
Ordained Clergy
Celebrant
Chaplain
Social Worker
Life Coach
Physician
Birth/Postpartum Doula
Licensed Massage Therapist
Psychotherapist/MSW/LCSW
Energy Medicine
Oriental/Ayurveda/Functional Medicine
First Responder/Paramedic
Herbalist/Aromatherapist
Lawyer
Accountant
Home Funeral Guide
Funeral Director
Ceremonialist
Hospice Executive
Other
Your Payment Structure
*
Check all that apply
Services provided at no charge
Donation determined by client
Fee for service
Sliding scale
Barter
Services paid by umbrella organization
Volunteer within community organization
Volunteer within Hospice
Other
Services You Currently Offer
*
Please check all that apply
Advance Care Planning
Early involvement (pre-hospice)
Vigiling/Active dying attendance
After death care/home funeral
Bereavement involvement
Community EOL education (non-doula specific)
End-of-Life Doula training
Aromatherapy
Business development
Celebrant/minister
Conscious dying guidance/education
Energy medicine
Funeral/memorial education
Green burial education
Legacy projects/planning
Legal/financial planning
Massage therapy
Organizing/downsizing/moving
Perinatal involvement
Personal Caregiver
Practical household help (meals, pet/house sitting, rides, etc.)
Reiki/Healing or Therapeutic touch
Retreats
Respite services
Soul midwife
Threshold Choir
Other
How You Would Like to Be Involved With NEDA?
Please check all that apply
I would like to have a voice in the development of this Network
I would like to have a voice in the development of this profession
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
I have free time to help
I have benefited from doula services in the past
I wish to support the Doula Model of Care
I am an aspiring EOLD
I have worked in a profession closely associated with EOLD and want to see it grow
I wish to contribute to and support the success of NEDA
Other
How Do You Hear About NEDA?
Please check all that apply
EOLD Training
NEDA Website
NEDA Newsletter
FaceBook Page
A Friend
Google Search
Other
NEDA End-of-Life Doula Directory
*
Yes, I want to be included in the website Directory
No, I do not want to be included in the website Directory
Upload Head Shot Photo
*
Please use a 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
Add 3% to my total amount to help cover the payment processing fees
