ICEA Certification Program Enrollment Form




Completion of this enrollment form with full payment will constitute enrollment in the ICEA certification program(s) indicated. Within three weeks of receipt of this enrollment form, ICEA will send the program materials. Enrollment and membership fees are non-refundable and non-transferable.

Contact Information

First Name:MI:Last Name:
Address:
City:State:Zip:
Country:
Phone Number:
Email Address:

Membership

I am a current member of ICEA.
Verified by ICEA Main Office:
I am not currently an ICEA member, but wish to join at this time. ($75)

Certification Programs

Childbirth Educator Certification Program

Traditional ($100)
Experienced ($100)
Previously Certified - Optional Study Modules Purchase ($30)
Name of Prior Certification Organization:
Previously Certified ($0)
Name of Prior Certification Organization:

Doula Certification Program

ICCE ($100)
Non-ICCE ($100)

Postnatal Educator Certifcation Program

ICCE ($100)
Non-ICCE ($100)

Perinatal Fitness Educator Program

($100)

Payment

Card Type: Visa      Mastercard
Card Number:
Exp. Date: /
3 Digit CVN Code:
I agree to be charged the TOTAL amount from the above checked options.