1. First name
2. Last name
3. Email
4. Cell phone number
5. Alternate phone
6. Mailing address

Please indicate which type of membership you are applying for.

1. Membership type < select one > Midwife, professionally active ($484.45)Midwife, professionally inactive ($30) Student midwife ($30)Supportive member ($30)
2. I'm a member of

3. I would like to add CAM membership to my PEIMA application ($110)