Application Affidavit for Birth Doula Recertification

APPLICATION/AFFIDAVIT FOR BIRTH DOULA RECERTIFICATION
ACTIVE STATUS

Please print legibly and complete the form in its entirety

1582 South Parker Road ● Suite 201 ● Denver, CO 80231

888-788-DONA (3662)   Fax: 303-755-7363

www.DONA.org   Certification@DONA.org

Full Name for Web site:

Mailing Address:

Referral Phone Number:
Cell Home

Referral E-mail Address:

I am changing from Inactive to Active status (Fee: $25.00US enclosed or Order Confirmation # )

I purchased a six (6) month extension for this recertification period (copy of receipt enclosed; check # or Order Confirmation # )

I wish to receive referrals and remain on the DONA International web site referral listing OR

I now wish to receive referrals and be included on the DONA International web site referral listing

I do not want referrals at this time

The following must accompany this Application. Please make note that all are enclosed

Recertification Active Status fee ($60.00US)

Check or Money Order # made payable to DONA International enclosed

I paid the Recertification Active Status fee on-line, Order Confirmation # (copy of receipt enclosed)

This signed Application/Affidavit for Doula Recertification—Active Status

All Alternative Continuing Education forms and supporting documentation, as required

Original evaluations of birth doula services from three (3) clients (=mothers) for whom I provided birth doula services during my current certification period

The original Birth Verification Form confirming my birth doula support of three (3) or more clients during my current certification period

Please read and sign the following statements:

I have completed at least fifteen (15) contact hours of continuing education approved by a recognized organization in a birth and/or parenting related field OR the equivalent of fifteen (15) contact hours of alternative continuing education OR a combination thereof during my current three (3) year certification period.

I have completed the chart on page 2 of this Application with detailed information

I have maintained continuous membership in DONA International during my current three (3) year certification period. Membership expiration date:

I supported a minimum of three (3) clients as a birth doula during my current three (3) year certification period.

I am keeping for my records a copy of all the documents mailed to DONA International with this Application

I agree to retain all associated documents not submitted with this Application and to provide these documents to DONA International within thirty (30) days of an audit request from the DONA Certification Committee.

I have once again read and agree to abide by the current DONA International Standards of Practice and Code of Ethics for birth doulas.

With my signature I verify that the above information is true and complete.

Office use only: Date rec’d:   File No.:   Membership Expiration:

APPLICATION/AFFIDAVIT FOR BIRTH DOULA RECERTIFICATION
ACTIVE STATUS
Page 2 – Chart of Contact Hours Earned

Please print legibly and complete the form in its entirety. Permission is granted to copy this form, as necessary

Recertifying Doula’s Name:

Continuing education approved by a recognized organization