This nomination form is for our annual
awards, coinciding with the
celebration of National Caesarean Awareness day.
We present awards to an Obstetrician, Doula and Midwife
who have provided excellent service in evidence-based,
woman-centred maternity care.
It is our chance to recognise these people
who make
such a difference to our birthing experiences.
Please copy the form below into an email,
or a word document which you can attach to an email,
and email it to us at:
Birthrites
Alternatively, you can print off this page and post
it to us at:
Birthrites
PO Box 62, Subiaco, WA, 6904
*****
Midwife:
Name:
_________________________________________________________________________
Address Details: ________________________________________________________________
State: _________________________ Phone Number: __________________________________
Your Comments: ________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
*****
Obstetrician:
Name:
_________________________________________________________________________
Address Details: ________________________________________________________________
State: _________________________ Phone Number: __________________________________
Your Comments: ________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
*****
Doula:
Name:
_________________________________________________________________________
Address Details: ________________________________________________________________
State: _________________________ Phone Number: __________________________________
Your Comments: ________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
*****
Your
Name: _____________________________________________________
Address Details: _________________________________________________
State: _____________
Phone Number: _______________________________
Email Address: __________________________________________________
Thankyou!
*Note - You can nominate for all 3 categories, or just one...
Whichever you feel most strongly about
- Your choice!
Your privacy will be ensured
(i.e., we won't tell the nominee who nominated them!)
