Doula Mentorship Application Form

Doula Mentorship Application Form
Information
Name *

First Name Last Name
Highest level of education
Current Occupation *
Date of Birth

Month Day Year
Date
Phone Number *

Area Code Phone Number
Back up phone number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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 Four $550 payments made May, July, September & November Working off balance with birth work from mentorship ($550 deposit is due my May 30th)
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 7 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 December, 30th 2020 *
By signing here I acknowledge that I am responsible for an initial $550 deposit by May 30th 2020 and either working off the balance through births and/or making the payments on time. I will be paying the balance in full by December, 1st 2020 if I was not able to attend enough births to cover what was left. *
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 at $400-450 and will claim them on my taxes even if that goes towards my balance. *
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Doula Mentorship Application Form

Information

About You

Payment Information