NYSALM

NYSALM Membership - Online Form Membership is for one calendar year beginning with your enrollment date
Personal Information
Name		Title (Select One): CM CNM SM SNM
Address:
City:		State:	Zip:
Phone:		Email:
Practice Information
Name:
Address:
City:		State:	Zip:
Phone:		Fax:
Email:		Website:
Check if you DO NOT want your practice information listed in the NYSALM Directory
NYSALM District: Our districts have changed! Not sure of your district? Click here
Employed by (check all that apply):
	Self	Government	Midwife (Other than Self)
	Physician	Educational Institution	Hospital
	Clinic	Faculty Practice	Military
	Other:
Type of Practice (check all that apply):
	Prenatal	Education	Intrapartum
	Endometrial Biopsy	Circumcision	VBAC
	GYN / Family Planning	Infertility Care	Colposcopy
	Primary Care	First Assist
Site of Deliveries (Check all that apply):
	Hospital	Birth Center	Home
Number of Births You Attend Per Year:
Total Number of Births Per Practice Per Year:
Does your practice precept students? Yes No
Educational Degrees (Check all that apply):
	Diploma	Associate	Bachelor's
	Certification Program	Master's	PhD / Doctorate
Malpractice Insurer:
	MLMIC	FTCA	Through ACNM (Contemporary)
	MMIP (Pool)	Other:
Who pays for your malpractice insurance?
	Practice doesn't carry malpractice insurance	Employer	Self
Have you ever been named in a malpractice lawsuit? (Your name will NOT be attached to this information)
	Yes	No	How many times?
Outcome of lawsuit:
Settlement		Jury decision for plaintiff	Jury decision for defendant
Type of clients (check all that apply):
	Private Insurance	Urban	Rural
	Medicaid	Suburban
Do you participate with private insurance?
	Yes	No
Membership Categories:
	Active (NY Licensed Midwives)	Associate
	Voting Members	Non-Voting Members
	Yearly - $150 2 Years - $275 Lifetime - $2250 Retired - $37.50	Student Midwife - $37.50 Associate - $37.50 (Includes midwifery supporters)
Donation for legislative effort (optional):
Donation for organization needs (optional):
Contributions or gifts to NYSALM are not tax-deductible as charitable contributions; however some portion of membership dues may be tax-deductible as ordinary and necessary business expenses

Check here if you will be SENDING A CHECK and not paying online. Click "Continue" below and then "click here to continue" on the following page to get NYSALM's mailing address.
Please note: After clicking the "Continue" button below, you will need to click on the link on the next page "click here to continue" in order to be brought to the PayPal page, where you can pay by credit card or paypal account.

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