Endorsement Form for the Illinois Midwifery Initiative (IMI)

I have read and am adding my name as an endorser of the Illinois Midwifery Initiative,

created by the Coalition for Illinois Midwifery (CFIM), October 2000 (revised April 2006)

Name __________________________________________________________________

(please print clearly)

Signed__________________________________________________________________

(Please list any degrees or credentials pertinent to your endorsing the IMI)

_____I would like to have my name/credentials displayed in conjunction with the document.

_____I would NOT like to have my name/credentials displayed in conjunction with the document.

If you are endorsing for an organization (your board must have approved the endorsement), please list the organization’s full name below.

Organization Name:_______________________________________________________________

Your position with the organization: __________________________________________________

_____I would like to have the name of my organization displayed in conjunction with the document.

_____I would NOT like to have the name of my organization displayed in conjunction with the document.

Individual names will not be displayed in conjunction with organizational names. If you wish to sign on both in the name of your organization as well as individually, please fill out two separate forms.

Address: ______________________________________________________________________

City: ______________________________________ State: ______ Zip: ___________________

Phone: ________________________________Fax: ____________________________________

Email: ________________________________________________________________________

Website: ______________________________________________________________________

Note: this information is strictly for use by CFIM and its Founding board members: Illinois Families for Midwifery,

Chicago Community Midwives and Illinois Council of Certified Professional Midwives for the promotion of

midwifery in Illinois.  Your information will not be given out or used for any other purpose.

Please print this form and mail to:

CFIM, c/o Rachel Dolan Wickersham, 901 E. Krage Drive, Addison,  IL 60101

Important note: Do NOT return this form via email. For legal purposes, we must have

your signature on file.