Provider Application | Southern Vermont Mat

top of page

Home
Donate
Get Involved
Meet the Founders
How It Works & Apply

687810257_122109958040810096_5788339061257667237_n_edited.png

First name*

Last name*

Email*

Phone*

Address*

Company name

Link

Counties you serve

Bennington

Windham

Windsor

Rutland

Other

Services you offer*

Birth doula

Postpartum doula

Lactation support

Childbirth education

Bodywork (chiropractic, massage, etc.)

Acupuncture

Other

Certifications and training:*

Years of experience:*

Any additional relevant background:

Tell us a bit about your approach to supporting families.*

Why are you interested in being part of this collective?*

Do you carry liability insurance (if applicable)?*

Anything else you’d like us to know about your work or practice?

I understand that submission of this application does not guarantee acceptance into the provider collective and that additional verification and membership fee may be required.

Providing perinatal support across Bennington, Windham, Rutland, and Windsor Counties, VT

bottom of page