Yes! I want to join other physicians and midwives in supporting the midwifery model
of care by joining Physicians for Midwives.

My membership is enclosed.

Name_________________________
Street_________________________
City__________________________
State/Province__________________
Country_______ Postal Code_____
Phone(___)____________________
FAX(___)_____________________
e-mail________________________


_____PHYSICIANS $25.00
_____MIDWIVES $10.00
_____STUDENT/APPRENTICE -0-

Make Check or Money Order payable to: Physicians for Midwives
Send with this form to:

Physicians for Midwives
112 Exchange Place
Lafayette, LA 70503