CEAOC New Membership Application (Please print this form and fill it out.)
Name________________________________________ Home Phone_____________________________
Address______________________________________ Work Phone_____________________________
City, State, Zip_________________________________ Cell Phone______________________________
Email Address_________________________________ Best Time to Reach You____________________
Membership Fee: $40.00
Childbirth Eduction Certification From:
____CEAOC ____ICEA ____Lamaze ____Bradley Other__________________________
Are you in the process of certifying? ____Yes ____No With___________ Completion Date________
Titles, Degrees, Licenses, or Certifications_____________________________________________________
______________________________________________________________________________________
Are you currently going to school?___________ Other languages spoken?___________________________
Where do you work?______________________________________________________________________
Volunteer work___________________________________________________________________________
Any other specialties?_____________________________________________________________________
Other organizations you belong to? (ILCA, La Leche League)_______________________________________
_______________________________________________________________________________________
Other clinics, hospitals, or programs with which you are affiliated____________________________________
_______________________________________________________________________________________
Would you like to be a part of your mentoring program? ____Yes ____No
Occasionally, CEAOC has the opportunity to share information and resources with members by
releasing our mailing list to other organizations. Do you give permission for your name to be released?
____Yes ____No
____________________________________________________________________________________________
Please make your check payable to CEAOC and mail both your payment and membership
application form to:
CEAOC Treasurer R. Rausch
19115 E Country Hollow
Orange, CA 92869
Name________________________________________ Home Phone_____________________________
Address______________________________________ Work Phone_____________________________
City, State, Zip_________________________________ Cell Phone______________________________
Email Address_________________________________ Best Time to Reach You____________________
Membership Fee: $40.00
Childbirth Eduction Certification From:
____CEAOC ____ICEA ____Lamaze ____Bradley Other__________________________
Are you in the process of certifying? ____Yes ____No With___________ Completion Date________
Titles, Degrees, Licenses, or Certifications_____________________________________________________
______________________________________________________________________________________
Are you currently going to school?___________ Other languages spoken?___________________________
Where do you work?______________________________________________________________________
Volunteer work___________________________________________________________________________
Any other specialties?_____________________________________________________________________
Other organizations you belong to? (ILCA, La Leche League)_______________________________________
_______________________________________________________________________________________
Other clinics, hospitals, or programs with which you are affiliated____________________________________
_______________________________________________________________________________________
Would you like to be a part of your mentoring program? ____Yes ____No
Occasionally, CEAOC has the opportunity to share information and resources with members by
releasing our mailing list to other organizations. Do you give permission for your name to be released?
____Yes ____No
____________________________________________________________________________________________
Please make your check payable to CEAOC and mail both your payment and membership
application form to:
CEAOC Treasurer R. Rausch
19115 E Country Hollow
Orange, CA 92869
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