WGOM Membership Application First name Last name Please check all that apply Certified Professional MidwifeCertified Nurse MidwifeLicensed MidwifeRetired MidwifeOther MidwifeTemporary Permit HolderOther If you selected other, please specify: If licensed in other states, please list here Mailing address City, State, Zip Code Email address Business Name Website Home Phone Office Phone Cell Phone Do you wish to be added to the Guild google group? YesNoCurrently Subscribed Licensed Midwives - do you wish to be added to the Guild website under Midwives? YesNoCurrently Listed Professional Guild members who are credentialed midwives (LMs or CNMs) may be eligible to serve on an Incident Review Team when the Committee determines that a formal peer review is needed. On alphabetical rotation, all eligible member midwives are asked to serve if reasonably able. Licensed Midwives - are you eligible to serve on an Incident Review Team if asked to serve? Please check all that currently apply to you: attended at least 50 primary births post midwifery credentialat least 3 years of experience post acquisition of midwifery credentialNOT a member of the DSPS-appointed Midwifery Advisory CommitteeNA / none apply to me Prospective members can join the Guild as Professional members or Associate members. Per WGOM Bylaws, Professional members are midwives who are Licensed Midwives or Certified Nurse Midwives that hold a license to practice midwifery in Wisconsin or are retired Midwives with an inactive license. Professional members also include students with a Wisconsin temporary permit to practice midwifery. Voting privileges are offered to Professional members. Associate Members may be any other person who is involved in or associated with midwifery. These members do not have voting privileges at this time. To become a member, please complete this form along with annual membership dues. Students, midwives in their 1st year of practice, non-practicing midwives and retired midwives are asked to pay dues at the sliding scale of $35-100 and practicing professionals are asked to pay dues at the sliding scale of $75-500. The Guild suggests 1–2% of a practice income as your dues to your professional organization. Dues must be sent each year to the Guild treasurer by January 1st of each year. You may become a NEW member at any given time within the year. Any member whose dues are unpaid (unless you have requested a fee waiver) by March 1st will forfeit their membership and be deleted from the WGOM website AND the WGOM Google email group. Payment can be made via PayPal as prompted upon submission of this form, or via check to the information listed below. WGOM offers a membership fee waiver for people who self-identify as being from a historically disenfranchised population or group or for those having a significant financial need and for whom the sliding scale fee would constitute a barrier to joining the Guild. I qualify for and request a membership fee waiver for this year, based upon the WGOM membership policy. YesNo I am mailing a checkI am sending a Paypal paymentMy fee is waived Payment Amount Applying for which calendar year? PayPal will request payment upon submission of this form. If you prefer a check or your fee is waived, you may exit PayPal. Checks should be payable to WGOM and mailed to: WGOM, Jade Dillman, 5420 20th Ave, Eau Claire, WI 54703. Questions? Email Jade at: email@example.com Please allow 2-4 weeks to be added to the Find a Midwife listing on our website and our member email list-serve.