Certification Extension Request

The SMC Full Circle Doula Birth Companion training program understands that challenges can impede a provisional doula in completing the certification within the 24-month requirement. If you need additional time, use this form to request a six-month extension at least two-months prior to the expiration date found on your provisional certificate.

Name*
First Last
Address*
Street Address Suite/Unit/Apt # City State ZIP Code
Email*

Please use the email associated with your initial registration for the SMC Full Circle Doula Birth Companion Training.
Phone*
Training Information
I trained*
Training Location*
City State / Province / Region
What was the "start date" of your training?*
MM slash DD slash YYYY
Upload a copy of your SMC Provsional Doula Certificate*
Accepted file types: png, jpg, pdf, Max. file size: 256 MB.
Certification Requirements
Please select what you have completed to date:*
- Select All
- CPR Card
- Food Handlers Card
- Attended Births (1-3)
- Postpartum Care Visits (1-3)
- Book Reports (1-5)
Audit Requirements
Select the number of required audit hours completed to-date:*
- Select All
- (4) hours of a natural childbirth or childbirth education class or workshop
- (2) hours of a breastfeeding/lactation class or workshop
Statement of Need
In 250 words or less, please explain why you need an extension?*
Fee*
Price:
Coupon
Total
$0.00

Save and Continue Later

Certification Extension Request

Training Information

Certification Requirements

Audit Requirements

Statement of Need