Massachusetts Midwives Alliance

Progress

1) Registration

2) Payment

3) Confirmation

First Name *
Last Name *
Name on Paypal Account *
Street Address *
City *
State *
Zip Code *
Phone *
Mobile Phone
Email *
License / credential issued by
License or certification #
Issue Date
Expiration Date
I want to be listed on the MMA website *	Yes No
Joining as a *	Member: $100 (voting) CPM, LM, CNM, Primary Midwife Under Supervision, DEM Supporting Member: $50(non-voting) Student, Apprentice Midwife, Doula, CBE, Others in the childbirth field
I am making a payment to waive work commitment *	Yes No
Select committees you are willing to participate on	Practice Guidelines/ Review Public Relations/Fundraising Legislative Peer Review / Continuing Education Board
Please fill in the information that you would like to appear in your listing
Comments
* *	Yes, I accept that when I join MMA as a member I agree to practice within the scope of the MMA Practice Guidelines.
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