CAPPA Training Registration Form Your First Name (required) Your Last Name (required) Your Address (required) City (required) Province (required) Postal Code (required) Your Contact Number (required) Your Email (required) Your Age (required) Training you are registering for: September 14-15, 2019 (Sat & Sun), 8:30AM-6:30PM, Markham, ONNovember 30-December 1, 2019 (Sat & Sun), 8:30AM-6:30PM, Markham, ON Name that would appear on your Certificate of Attendance Your Current Occupation (required) How did you first learn about postpartum doulas? Tell me a little bit about your prenatal, birth and/or postpartum experience: (required) Tell me a little about yourself and why do you want to be a postpartum doula? (required) How did you hear about our training? (required) Save 5% when you sign up with a friend! To receive this rebate simply list your friend’s name below. Both you and your friend will receive a 5% rebate only after you have both registered, paid and attend the same training dates. The 5% rebate will be paid back in cash upon attendance of the training. (Does not apply to training transfers). Put in N/A if not applicable. Friend's name: *I verify that all the information provided in this registration form is true. I further affirm that by filling out this registration form and by typing my name in the box below, I agree to the terms as given herein, and my electronic signature is in lieu of my physical signature. By submitting this registration form, you agree to the following terms and conditions: I agree to allow CAPPA Faculty to: • Publish my name, phone number, and email address for the doula trainee class list & referral list. • Take photographs of the training which may include me, as well as allow CAPPA Faculty and CAPPA to use these photographs for promotional purposes online and in print. • Use quotes from my training evaluations (which I may fill out anonymously) for promotional purposes online and in print. I agree to the following policies: • I am at least 18 years of age. • I understand that CAPPA does not assume liability for adverse reactions to foods consumed, or items one may come into contact with while at any CAPPA Event, Training or Activity you may attend whether inside or outside of CAPPA planned location. • I have read and agree to the cancellation policy • I understand that I may not record the training workshop (audio or video). • I understand that I may not photograph any PowerPoint slides, training materials, certificates of completion, or any other intellectual property belonging to CAPPA or my trainer. • I may not reproduce, publish or distribute any materials in the training manual. • I may not reproduce, publish or distribute any certification materials, other than for the purpose of fulfilling my certification requirements (i.e. copying the evaluation forms for my clients to fill out). • I may not reproduce, publish, photograph, share, email, or distribute any materials in the training handouts or manual other than for the purpose of using them for my personal business as a educator. • I understand that this course is only one step in becoming a CAPPA Certified Childbirth Educator, Labour Doula or Postpartum Doula. There are several other steps that must be completed by the student after the training in order to be eligible for certification by CAPPA. • I may take photographs of CAPPA Faculty and the participants ONLY with the express permission of CAPPA Faculty and the participants. I may not use these photographs for any purpose other than personal use. No photographs from the training may be distributed via email, posted to my website, Facebook account, or other online media, unless express permission has been granted. No photographs may be used for any advertising purpose, nor sold or transferred to any other party. • Babies/children are not permitted at training. Nursing babies are welcome during lunch. Off-site childcare arrangements are the sole responsibility of the trainee. • I understand that CAPPA Membership, the Childbirth Educator Certification Packet, and the CAPPA Academy Fee are not included in the price of the workshop. • Certificate of training completion is given only if the entire training is attended and training fees are paid in full. • I understand that I am not registered for this training until I have completed this registration form AND my payment has been received by Su Yin Jordan. • I understand that I will receive an email confirmation of registration from Su Yin Jordan within 2 business days. If I do not receive a confirmation, I will contact Su Yin Jordan at firstname.lastname@example.org to confirm that my registration was received. • I understand that in the event of a hazardous weather/travel issues, a makeup options will be provided and that Su Yin Jordan is not responsible for all travel expenses, including but not limited to airfare and hotel.