DIRECTIONS: Please copy the following application into a word processing program, complete the information below, print, and sign the Confidentiality Agreement. Then scan/photo the document as a PDF/JPEG and attach the new form into an email. Also include a professional resume detailing previous birth, counseling, medical or midwifery work. Send to:


Name of Applicant:






Please Indicate Appropriate Pre-requisite Qualifications:

  • Certified/Experienced Doulas with at least 20 births
  • Certified Childbirth Educators with at least 20 couples trained
  • Midwifery Students with at least 2 years study or 20 birth assists
  • Neonatal/Obstetric Nurses with at least one year L & D floor experience and knowledge of out-of-hospital and physiologic birth
  • Midwives with knowledge of out-of-hospital and physiologic birth
  • Physicians with knowledge of out-of-hospital and physiologic birth
  • Other licensed professionals who work with perinatal women and who have knowledge of out-of-hospital and physiologic birth

Please indicate the Pathway for which you are applying:           

Pathway ONE                      Pathway TWO


  1. Please detail how you intend to use the information gained through the Perinatal Bereavement Specialist Certificate Program.


  1. Explain any professional experience with pregnancy loss you have experienced. How do you feel you handled your professional obligations to your clients/patients?


Confidentiality Agreement

It is understood and agreed to that the below identified discloser of confidential information may provide certain information that is and must be kept confidential. To ensure the protection of such information, and to preserve any confidentiality necessary under patent and/or trade secret laws, it is agreed that

  1. The Confidential Information to be disclosed can be described as and includes:

Technical and business information relating to proprietary ideas and inventions, ideas, documents, processes,  patentable ideas, trade secrets, drawings and/or illustrations, existing and/or contemplated products and services, research and development, production, costs, finances and financial projections, customers, clients, marketing, and current or future business plans and models, regardless of whether such information is designated as “Confidential Information” at the time of its disclosure.

  1. The Recipient agrees not to disclose the confidential information obtained from the discloser to anyone unless required to do so by law.
  2. This Agreement states the entire agreement between the parties concerning the disclosure of Confidential Information. Any addition or modification to this Agreement must be made in writing and signed by the parties.
  3. If any of the provisions of this Agreement are found to be unenforceable, the remainder shall be enforced as fully as possible and the unenforceable provision(s) shall be deemed modified to the limited extent required to permit enforcement of the Agreement as a whole.

WHEREFORE, the parties acknowledge that they have read and understand this Agreement and voluntarily accept the duties and obligations set forth herein.

Recipient of Confidential Information:

Name (Print or Type):



Discloser of Confidential Information:

Name (Print or Type): Angelique Chelton- DBA Hearthside Perinatal Bereavement Care

Signature: (e-signature)

Date: 8/17/2015