Add Your Listing to Our New Referral Site

Sign up before December 31, 2004 and your first year is free!

The normal registration fee is being waived during this introductory period. After the first year, there will be a fee of $35 per year to be included in this database. After entering your information on this page, you will be asked to enter payment information. Only after this payment has been validated will your listing become active on the site. Approximately six weeks before the expiration of your listing, you will receive an email reminder to renew. This reminder will be sent to the then current email address on your record.

After enrolling you will have the ability to edit and update your information, including your email address and other contact information. An email confirming your enrollment and providing details on updating your information will be sent as soon as your account is activated.

Please note that this site is strictly for promoting services, not products. We reserve the right to remove a listing if we receive complaints of insensitive practices to the birthing woman or the newborn.

Step 1, Enter your Information

Required fields are marked with "*."

General Information
First Name*:
Last Name*:
Business Name:
Phone*:
Email*:
Website:	http://
Photo:	Click here to upload a photo to be displayed with your listing We strongly recommend posting a photo. This will help prevent others from attempting to practice under your name. Photos will be scaled to be 150px in their largest dimension Photos should be saved in .jpg format     .gif and .png are also acceptable
Account Setup
login ID*:
Password*:
Confirm Password*:
Use this ID and password to log in and update your information. IDs can be up to 30 characters long, Passwords can be up to 16 characters long.
Security Question:
Security Answer:
This Question and Answer will be used to verify your identity should you forget your login ID and password. Please choose a question that you will always know the answer to, but that others would have a hard time guessing. Popular questions are "Mother's maiden name,""First pet's name," etc.
Service Details
Service Category*:	Birth Centers Birth Support Breastfeeding Support Childbirth Preparation Classes Excercise Programs Massage Therapist Midwives New Mothers Groups OBGYNs Other Birth-Related Services Pediatricians Post-Partum Care
Other Birth-related Services: (or specialties)
Years in practice*: references available
Hours:	"9 to 5, Mon thru Sat"
If you are a professional midwife, OBGYN or Birth Support:
Number of visits offered before birth:
Number of visits offered after birth:
Are you a...	home birth, birth center, and/or hospital birth practitioner?
Location
City*:
Service Area:
State/Province:
Country:
Do you practice from...	home and/or office
Experience & Training
The following information allows us to verify the quality of list members. Training and reference information will not be made available to site visitors.
Training/Certification(s):
1. Name of Program*:
Date Completed*:	"mm/yyyy", or just "yyyy"
Phone*:
2. Name of Program:
Date Completed:	"mm/yyyy", or just "yyyy"
Phone:
3. Name of Program:
Date Completed:	"mm/yyyy", or just "yyyy"
Phone:
Client References:
1. Name*:
Phone*:
2. Name:
Phone:
3. Name:
Phone:
Professional References:
1. Name*:
Phone*:
2. Name:
Phone:
3. Name:
Phone:
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