Doula Mentorship Application Form

Name*

First NameLast Name

Highest level of education

Current Occupation*

Date of Birth

Date

Phone Number*

Area CodePhone Number

Back up phone number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Have you taken any Doula training yet?*

YesNo

If you have already takes a different Doula program, which one?

Please provide your full credit card billing information along with expiration and security code. This will only be charged if you become delinquent over 60 days and all other attempts of have been exhausted.

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

Date of Registration*

Date

Payment options*

One time payment of $2,000$500 deposit w/ equal payments of $250 for 6 months. The deposit is required to hold your spot and due at signing.

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 program that costs $2,000. If I choose to leave the program at any time I am still responsible for the $2,000 fee due in full within 9 months of the first day of class.*

By signing here I acknowledge that I am responsible for an initial $500 deposit to reserve my spot in the program when I sign up. I agree to make the 6 months payments of $250 on time toward the remaining balance, as indicated above. Monthly payments are due the 1st of each month starting the 1st of the month once class starts. We require a credit card on file in case you go 60 days past due and a 3% processing fee will be added. There will be invoices sent out so this is not a surprise. If you default on payments with no communication or attempts, we will not issue certifications. We prefer monthly payments be made via Venmo & Zelle for payments. *

By signing here I acknowledge that I am responsible for a min. of 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 use and communicate with the back up Doula chosen by the client to fulfill the role as their Doula. I will not receive compensation for that family as it will go to the back up Doula. Using a back up should be avoided at all costs. If you send a back up to 3 families within our program we will take you off the website for hire. *

By signing here I acknowledge that I will be compensated for the births I attend through In Joy Birth's mentorship program as the primary Doula at $500, births I assist at $150 and postpartum care at $20hr with the ability work and move up to $26hr. I understand I am responsible for claiming my income and filing my taxes as an independent contractor accordingly. Tax documentation will be provided during tax season each year.*

By signing here you acknowledge that being a Doula is a service based industry. In Joy Birth strives to provide exceptional Doula care and customer service. If a client is unsatisfied and requests a refund, and we find it warranted, you will repay the funds that were paid out to In Joy Birth LLC. Please note, all efforts to avoid refunds will be made.

Please give us your Credit card to keep on file. Please note that your card will not be charged unless you are past 60 days past due and all attempts to collect have been ignored. a 3% processing fee will be added. This is a secure site but if you'd prefer to call us with this information instead that is also fine. security code & exp. date included too

Name: Signature: Date:

This is a fill in the blanks field. Please add appropriate blank fields and text.

By signing here you agree and acknowledge that this mentorship comes with intellectual property of Heather Rich and Alyssa Kaplan, owners of In Joy Birth. All training and education materials/resources come from years of market research and curriculum building. This is a legally binding contract that prohibits you and any business you create from creating your own Doula training or mentorship program for 10 years after completing this program. This includes placenta encapsulation, CBE, Birth or Postpartum trainings. If you live over 70 miles away from Winter Park, FL, we are open to negotiations conversations.

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Doula Mentorship Application Form

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