Doula Mentorship Application Form
Information
Name
*
First Name
Last Name
Highest level of education
Current Occupation
*
Date of Birth
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Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Back up phone number
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Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Have you taken your Doula training yet?
*
Yes
No
About You
What made you want to become a doula?
*
What are you hoping to get out of the mentorship?
*
Is your current job/lifestyle flexible so you can leave at any time for births?
*
If you have any special needs/requirements please let us know
Payment Information
Date of Registration
*
-
Month
-
Day
Year
Date
Payment options
*
One time $2,200 payment
Deposit of $550 due at time of commitment. $275 per month beginning January 8th, 2022. Payments are due on the date of monthly workshops thereafter.
By signing here I acknowledge I will provide judgment free care for all birthing families despite race, gender, religion, sexual orientation or Identity as well as parenting choices ie: birthing place, vaccines, epidural..etc.
By signing here I acknowledge that I am entering into a 6 month program that costs $2200. If I choose to leave the program at any time I am still responsible for the $2200 fee due by July 1, 2022.
*
By signing here I acknowledge that I am responsible for an initial $550 deposit to reserve my spot in the program. I agree to make payments on time toward the remaining balance, as indicated above. I will be paying the balance in full by July 1, 2022.
*
By signing here I acknowledge that I am responsible for 1 prenatal visit, the labor and birth and 1 postpartum visit for each birthing family I am assigned to within this mentorship program. If I am unable to attend I will provide a back up doula from within the program and will not receive compensation for that family as it will go to the back up doula.
*
By signing here I acknowledge that I will be compensated for the births I attend as primary doula at $500, births I assist at $150 and postpartum care at $15-$20/hour. I understand I am responsible for claiming my income and filing my taxes as an independent contractor accordingly.
*
Submit
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