Free POC Community Doula Training
Please pick which session date is best for you to attend:
Friday, May 14-16, 20201 (Fri: 5 pm - 9 pm; Sat. & Sun.: 8 am - 5 pm)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you a person of color?
*
Yes
No
Have you ever breastfed?
*
Yes
No
If yes, please share your breastfeeding experience.
Are you currently breastfeeding?
Yes
No
Why are you interested in becoming a community doula?
Do you have any dietary restrictions?
No
Yes
If yes, please list:
Do you childcare support for your children. Note that breastfeed babies under 6 months may attend with you?
Yes
No
N/A
Do you agree to attend all days of the training? Do you agree to be fully engaged during the training? Do you agree to wear your mask and practice social distancing as much as possible during the training?
*
Yes
No
Photo will be taken during this training to use on social media, publication, and sent to funders. Do you consent to being photographed?
*
Yes
No
Signature
Submit
Should be Empty: