Doula Training Scholarship Application
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Address
Street Address Line 2
City
State / Province
Zip Code
County of Residence
What Race do you identify as?
*
White
Black/African American
Native American/Alaskan Native
Asian
Pacific Islander
Multiracial
Other
What Ethnicity do you identify as?
*
Hispanic
Non-Hispanic
Language(s) in which you are comfortable providing service
*
English
Spanish
Other
Have you ever been or are currently a Medicaid recipient?
*
Yes, currently
Yes, in the past
No
Do you have children?
*
Yes
No
How many children do you have?
Highest level of education
*
Less than High School
High School Diploma or GED
Some College but no Degree
2 Year Degree
4 Year Degree or higher
Other
List of community activities and/or previous volunteer work in the community
How long have you lived in this community?
*
Do you plan to stay in the area for the next 3 - 5 years?
*
Yes
No
Do you have any maternal-child health experience?
*
Yes
No
Maternal-Child Health Experience
Share why this training is important to you
*
Estimated household income?
Less than $25,000
$25,000 - $34,000
$35,000 - $49,000
$50,000 - $74,000
$75,000 - $99,000
More than $100,000
Are you interested in becoming a Certified Doula?
*
Yes
No
Do you have reliable transportation?
*
Yes
No
Are you able to be on-call and available 24 hrs/day for clients as they approach their due date?
*
Yes
No
How much time do you envision committing to providing doula services?
*
Full-time (4 births per month)
Part-time (2 births per month)
Minimal (1 birth per month or every other month)
Have you completed/passed a Level II background screening within the last 5 years?
*
Yes
No, but would be willing to undergo a Level II background screening in accordance with local laws/regulations
No, and I would NOT be willing to undergo a Level II background screening in accordance with local laws/regulations
Are you CPR Certified?
*
Yes, please provide expiration date below
No, but would be willing to get CPR Certified
No, and I would NOT be willing to get CPR Certified
CPR Certification Expiration Date
-
Month
-
Day
Year
Date
Have you received the flu vaccine?
*
Yes, and I would be willing to provide proof of vaccine
No, but I would be willing to receive the vaccine if the medical facilities where I would provide Doula services require this vaccine
No, and I would NOT be willing to receive the vaccine
Have you received the COVID-19 vaccine?
*
Yes, and I would be willing to provide proof of vaccine
No, but I would be willing to receive the vaccine if the medical facilities where I would provide Doula services require this vaccine
No, and I would NOT be willing to receive the vaccine
Are you currently employed?
*
Yes
No
Employment status
Full-time
Part-time
Other
Name of Employer
Job Title
Start Date
-
Month
-
Day
Year
Date
Employer's address
Employer's Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you legally authorized to work in the United States?
*
Yes
No
Personal References
Name
*
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Name
*
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Name
*
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Electronic signature
*
Questions or comments
Submit
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