1 RENEWAL FORM Blank - infantmassagewinc.comColor 2016 CIMI® Manual Replacement $125 value, save...
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Infant Massage WINC, World Institute for Nurturing Communication d/b/a for International Association of Infant Massage -- IAIM ® The original IAIM® organization – origin 1970s, incorporated in the USA since 1986 Web: www.infantmassagewinc.com e-mail: [email protected] Fax: 805.299.4563 Ph: 805.644.8524 Referral Phone: Alt. Phone: Fax: Languages (other than English): 1. WINC™/IAIM ® Certification #:_________________. Expiration Date: __________________ 2. Date Certification(s) Awarded: CIMI®: ___________ CIMI®-2: ____________ NICU: _______ Touch In Labor: _________. 3. Professional Background (optional, not listed on card, database info only): ________________________________________________________. 4. Approx. number of families taught over the past year (information used for grants and research study)? Current Year: _______ 5. Are you currently listed on Web? Name • Phone for Referrals • City & State q Yes, ADD/continue FREE Infant Massage WINC web Referral List Please Initial: X__________ q No, do not wish to be listed on website. Please Initial: X__________ CURRENT members only are authorized to teach copyrighted IAIM®/WINC™ programs and use our trademarks ‘CIMI ® ’ & ‘IAIM ® ’ Annual registration with Infant Massage WINC Renewal Fee: $85 $ Donation (tax deductible) Thank you for your donation and commitment to all the families of the world. Optional Any Amount $ Color 2016 CIMI® Manual Replacement $125 value, save $30 w/renewal only (outside continental USA $115) $95 $ Black & White 2016 CIMI® Manual (outside continental USA $85) $65 $ CIMI® Teaching Tools - delivered by email Parent Certificates $25 $ Fact Sheets $35 $ Brochure $40 $ Parent Handouts $30 $ ($125 VALUE) Save $20 *w/renewal only All 4 – certificates, fact sheets, handouts, & brochure $105 $ Business Cards (see back for details – Mailed) q Premium $155 (500) / q Standard $70 (100) $155/$70 $ CIMI® PowerPoint® (PDF file format) (see back of sheet for list of titles) (delivered by email only) Check Choice (see back of sheet): (#1-#5 other items) q6 q7 q8 q9 q10 q11 q12 q13 q14 q14B q15 q16 q17 q18 q19 q20 $40.00 each $40 x ___ = $ ($120 VALUE) Save $15 w/renewal only Any 3 PowerPoints in multiples of 3 w/renewal $105 $ $20 Website Annual Enhanced Referral Listing (free listing below) 200 character limit (Use separate sheet or email information) $ 20.00 $ TOTAL Amount Enclosed $ USD IMPORTANT NOTE: To receive newsletters and announcements a current email address* is required. Renewals will continue to be sent via US postal service. *If you opted out of emails in the past and wish to continue to receive them you must submit a different email address. E-Mail Address: OFFICE USE ONLY Credit Card: ❍ Process c Enter: ❍ Deposit ❍ Web «ListOnWeb» ❍ Database Tools → ❍ Email PDF ❍ Mail manual Form «TrainerCode»2016 We provide 4 convenient ways for you to renew: • Call the office to renew by credit card: 805-644-8524 • On-line at www.infantmassagewinc.com by credit card (click on “CIMI/CIIT Renew & Tools”) • Mail form with check or credit card info to: Infant Massage WINC • PO Box 2447 • Ventura CA 93002 • Fax form with credit card info to: 805-299-4563 A. Check $ _________________ made payable to: Infant Massage WINC. Check #: . Please write Certification # «MBRType»«MBRNumber» on check. Your canceled check is your receipt. B. (Visa/MasterCard/Amex/Discover) ___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___ Credit Card Signature: ________________________________________ Exp. Date: ___________ (Credit Card Receipt is sent by email, Renewal pending credit card approval) Credit Card BILLING Address (if different from Mailing Address) Street: ______________________________________________________________________________ City: ___________________________________________State:__________ Zip:________________ Infant Massage WINC™ PO Box 2447 ççççNEW ADDRESS Ventura, CA 93002 çç Name: Address: City, State, Zip/Postal: Certification Renewal Form Please correct and/or complete the following and return entire form to office (make copy for your records if needed) PLEASE NOTE WE HAVE A *NEW ADDRESS* It’s Time to Renew!
Transcript of 1 RENEWAL FORM Blank - infantmassagewinc.comColor 2016 CIMI® Manual Replacement $125 value, save...
Infant Massage WINC, World Institute for Nurturing Communication d/b/afor International Association of Infant Massage -- IAIM®
The original IAIM® organization – origin 1970s, incorporated in the USA since 1986 Web:www.infantmassagewinc.com�e-mail:[email protected]�Fax:805.299.4563�Ph:805.644.8524
Referral Phone:
Alt. Phone: Fax: Languages (other than English):
1.WINC™/IAIM®Certification#:_________________.ExpirationDate:__________________2.DateCertification(s)Awarded:CIMI®:___________CIMI®-2:____________NICU:_______TouchInLabor:_________.3.ProfessionalBackground(optional,notlistedoncard,databaseinfoonly):________________________________________________________.4.Approx.numberoffamiliestaughtoverthepastyear(informationusedforgrantsandresearchstudy)?CurrentYear:_______5.Are you currently listed on Web? Name • Phone for Referrals • City & State q Yes, ADD/continue FREE Infant Massage WINC web Referral List Please Initial: X__________ q No, do not wish to be listed on website. Please Initial: X__________
CURRENT members only are authorized to teach copyrighted IAIM®/WINC™ programs and use our trademarks ‘CIMI®’ & ‘IAIM®’
Annual registration with Infant Massage WINC Renewal Fee: $85 $ Donation (tax deductible) (optional) $ Thank you for your donation and commitment to all the
families of the world.
Optional
Any Amount
$ Color 2016 CIMI® Manual Replacement $125 value, save $30 w/renewal only
(outside continental USA $115) $95
$ Black & White 2016 CIMI® Manual (outside continental USA $85) $65
$
CIMI® Teaching Tools - delivered by email Parent Certificates $25 $ Fact Sheets $35 $ Brochure $40 $ Parent Handouts $30 $ ($125 VALUE) Save $20 *w/renewal only All 4 – certificates, fact sheets, handouts, & brochure $105 $
Business Cards (see back for details – Mailed) q Premium $155 (500) / q Standard $70 (100) $155/$70 $
CIMI® PowerPoint® (PDF file format) (see back of sheet for list of titles) (delivered by email only)
Check Choice (see back of sheet): (#1-#5 other items) q6 q7 q8 q9 q10 q11 q12 q13 q14 q14B q15 q16 q17 q18 q19 q20
$40.00 each
$40 x ___ = $
($120 VALUE) Save $15 w/renewal only Any 3 PowerPoints in multiples of 3 w/renewal $105 $
$20 Website Annual Enhanced Referral Listing (free listing below) (optional)
200 character limit (Use separate sheet or email information) $ 20.00
$
TOTAL Amount Enclosed $ USD
IMPORTANT NOTE: To receive newsletters and announcements a current email address* is required. Renewals will continue to be sent via US postal service. *If you opted out of emails in the past and wish to continue to receive them you must submit a different email address. E-Mail Address:
OFFICEUSEONLYCreditCard:❍Processc
Enter:❍Deposit❍Web«ListOnWeb»❍Database
Tools→❍EmailPDF❍MailmanualForm «TrainerCode»2016
We provide 4 convenient ways for you to renew: • Call the office to renew by credit card: 805-644-8524 • On-line at www.infantmassagewinc.com by credit card (click on “CIMI/CIIT Renew & Tools”) • Mail form with check or credit card info to: Infant Massage WINC • PO Box 2447 • Ventura CA 93002 • Fax form with credit card info to: 805-299-4563
A. Check $ _________________ made payable to: Infant Massage WINC. Check #: . Please write Certification # «MBRType»«MBRNumber» on check. Your canceled check is your receipt.
B. (Visa/MasterCard/Amex/Discover) ___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___
Credit Card Signature: ________________________________________ Exp. Date: ___________ (Credit Card Receipt is sent by email, Renewal pending credit card approval)
Credit Card BILLING Address (if different from Mailing Address)
Street: ______________________________________________________________________________ City: ___________________________________________State:__________ Zip:________________
Infant Massage WINC™ PO Box 2447 ççççNEW ADDRESS Ventura, CA 93002 çç Name: Address: City, State, Zip/Postal:
Certification Renewal Form Please correct and/or complete the
following and return entire form to office (make copy for your records if needed)
PLEASE NOTE WE HAVE A *NEW ADDRESS*
It’s Time to Renew!
Fact Sheets (7 areas) - $35 (Delivered by email only) PDF file self-printing format. Print1orasmanyasyouneed 1) Overview of infant massage 2) Adolescent mothers & their baby 3) Parents of children with developmental delays 4) Adoptive parents & their babies 5) Mothers in substance abuse recovery & their baby 6) Well parents & their well babies 7) Bibliography & resource materials
Brochure - $40 (Delivered by email only) PDF file self-printing format. Print1orasmanyasyouneed. Perfect for Introducing yourself to convey the benefits of your work as a CIMI®.
Parent Certificates - $25 (Delivered by email only) PDF file self-printing format. Print1orasmanyasyouneed Give your parents a “graduation” certificate that they can proudly display. It also lets their friends and family know about your classes!
Business Cards (proof sent by email) q Extra thick premium; 500 cards - $155 (reg. $185) q Standard card; 100 cards - $70 (reg. $100) (Delivered by mail)
Please choose: q Matte q Glossy (Left Side of Card) NAME: __________________________ TITLE: CIMI®, _____________________ (Right Side of Card) Tel: ______________________________ Cell: ____________________________ Email: ___________________________ Other: ___________________________
6-20. PowerPoint Presentations $40 each
q6.Triad Model Epigenetics
q7. Prep for Massage Class
q8. States and Cues
q9. IRRS
Interaction,Relief,Relaxation,&Stimulation
q10. Bonding & Attachment
q11. Newborn Massage
q12. Parent Class *New*
q13. Conscious Parenting
q14. NICU Infant Massage
q14B. Child w/Special Needs q15. Crying
q16. Growing Child Massage
q17. Brain Development
q18. In-Service Presentation q19. What is Marketing? q20. Marketing Baby Class
5. Parent Handouts - $30 Series of handouts along with stroke summary (Delivered by email only) PDF file self-printing format. Print 1 or 1001
Front of card
Back of Card
