Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Place of Employment:

Email:

Original Course Location:

Original/Last Certification Date:

Are you an independent instructor or on staff at a hospital:

Number of couples taught this year:

Requirements

1. All members must submit a current class outline. Please see our samples of what information to include and how to format it for this form.

What changes have you made on your outline since your last Recertification?

Current Outline (Please separate each item, as in this sample):

2. $45.00 for a 2-year Recertification Renewal Fee.
3. Choose one of the following:

1. Fifteen contact hours (CEU's) in a two-year period directly or indirectly related to childbirth (copies must be mailed or faxed). $45.00 
2. Submit three book reviews of current books relating to childbirth education and a case study of a challenging class situation you have had. Please relate the problem or situation and how you dealt with it. $45.00
3. Attend one day at an ACBE site for recertification. $45.00
4. Attend one day at an ACBE site for recertification plus receive 6.5 CEUs for attending . $80.00
5. I have already recertified for my two-year period but would like to attend the one day at an ACBE site for the 6.5 CEUs. $35.00
   
   
   

If you chose to submit book reviews, please paste them into the form below:

Case study:

If you chose to attend one day at an ACBE site, please indicate the location and date below:

Please attach a short note to tell us how you're doing and about your classes. We would value an article by you which could be published in our newsletter. All educators benefit from sharing ideas, hearing how you handled an unusual situation in class, or a motivating story to brighten our day. Having your article published can benefit you as well.

Do we have permission to print any of the following in our newsletter?
Book Report Case Study or any comments

How can the Academy help you?

How would you like your name printed on the certificate?

How will you be paying for your recertification?
Check Credit Card Paypal

*** You will need to contact us if you will be paying by credit card to send us your information over the phone or by fax. The following page after you send this form will allow you to pay via Paypal and will also have our mailing address and fax number. ***