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Birth Justice Care Fund Application
The Birth Justice Care Fund was originally a SisterSong Birth Justice Team needs-based initiative, for Georgia, Kentucky, and North Carolina residents, in response to the social crisis that communities of color are experiencing more critically due to the COVID-19 Pandemic and the U.S’s High Black Maternal Mortality Rate. The relief funds are intended for Black and other birthing people of color, especially Queer and Trans folks in need of support during their pregnancy and within one year postpartum. The Fund is now open and available for residents of Georgia, Kentucky, North Carolina, and Florida.
Are you filling this form out online or onsite at an event?
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Online
Onsite at event w/SisterSong
Are you applying on behalf of someone else?
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Yes
No
If so, why?
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The applicant has a Disability
The applicant doesn't have access to application (internet)
The applicant is temporarily incapacitated (e.g. sick, hospitalized, depressed, etc.)
None of the above
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What language are you completing this form in?
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English
Spanish
Other
Race/Ethnicity of Applicant
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African American
Caribbean
Native American Indigenous
LatinX
Asian
Pacific Islander
Multiracial/Biracial
White/Caucasian
Middle Eastern
Another race/ethnicity
Race/Ethnicity of Baby
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African American
Caribbean
Native American Indigenous
LatinX
Asian
Pacific Islander
Multiracial/Biracial
White/Caucasian
Middle Eastern
Another race/ethnicity
How many people are in your household or will be once your baby is born?
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a. Adults 18+
b. Children Under 18
c. Total Number of People
What is your household income?
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Under $15,000
$15,001-$25,000
$25,001-$35,000
$35,001-$45,000
$45,001-$55,000
$55,001-$65,000
$65,001-$75,000
$75,001-$85,000
$85,001-$95,000
$95,001-$105,000
$105,001-$115,000
$115,001-$125,000
more
Do you receive any of the following public assistance?
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WIC
SNAP
SSI
TANF
Medicaid
N/A
Another type of public assistance (fill in)
When is/was your delivery date/due date? Applicants must be between 4 weeks pregnant and/or one year postpartum to apply.
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-
Month
-
Day
Year
Date
How did you hear about the BJ Care Fund?
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Social Media
Website
Newsletter
Birth Worker (provide name)
Birth Justice Programming
Essence Festival
Friend
RJ Bus Tour
Other
Birthworker Referral Name
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What support are you requesting?
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Items
Services
Please indicate which ITEMS you need
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Diapers
Baby Wipes
Bassinet
Breast Pump
Stroller
Carseat
Please indicate which SERVICES you need
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Birth Doula
Postpartum Doula
Full Spectrum Doula
Maternal Mental Health Therapist
Lactation Support Professional
Please select your top 3 choices for a Birth Doula
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Alexis A. Crawford
Alicia Walker-Patterson
Andrea Blanton
Aura Love
Bianca Hamilton
Breanna Grant
Briana Simmons
Calvis Jones, M.S.- MCCHW
Claudia "Cookie" Gonzalez
Donna JACOBS, MSW, Doula Practitioner
Doulaw Park
Dr. Jane Grant, PT
Esther Rose Louis
Haydee Liz Salas
Jekisha Elliott, MHA, CD-L
Jennifer Thompson
JuJu James
Kaci Griffin
Kenya C. Webb. MS
Khye Tyson
Kiera Hereford
Kristina Cheek, CLC, CHW, PPN,
Krystal Reese
Lo Bullock
Mama Kei
Mary Miller
Mckenzie Mitcham (MAC)
Michelle Singleton
Passion Smith
Racquel Washington
Safira ‘SPA Doulah’ Zayas
Shannon Holloway
Tiffany Bellfield El-Amin
Vanya Francis
Whitney Williams-Black
Please select your top 3 choices for a Postpartum Doula
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Bianca Hamilton
Esther Rose Louis
Jekisha Elliott, MHA, CD-L
Kenya C. Webb. MS
Kristina Cheek, CLC, CHW, PPN,
Krystal Reese
Mary Miller
Shannon Holloway
Mama Kei
Alexis A. Crawford
Alicia Walker-Patterson
Andrea Blanton
Aura Love
Breanna Grant
Briana Simmons
Calvis Jones, M.S.- MCCHW
Claudia "Cookie" Gonzalez
Donna JACOBS, MSW, Doula Practitioner
Doulaw Park
Dr. Jane Grant, PT
Haydee Liz Salas
Jennifer Thompson
JuJu James
Kaci Griffin
Khye Tyson
Kiera Hereford
Lo Bullock
Mckenzie Mitcham (MAC)
Michelle Singleton
Passion Smith
Racquel Washington
Safira ‘SPA Doulah’ Zayas
Tiffany Bellfield El-Amin
Vanya Francis
Whitney Williams-Black
Please select your top 3 choices for a Full Spectrum Doula
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Bianca Hamilton
Esther Rose Louis
Jekisha Elliott, MHA, CD-L
Kenya C. Webb. MS
Kristina Cheek, CLC, CHW, PPN,
Krystal Reese
Mary Miller
Shannon Holloway
Mama Kei
Alexis A. Crawford
Alicia Walker-Patterson
Andrea Blanton
Aura Love
Breanna Grant
Briana Simmons
Calvis Jones, M.S.- MCCHW
Claudia "Cookie" Gonzalez
Donna JACOBS, MSW, Doula Practitioner
Doulaw Park
Dr. Jane Grant, PT
Haydee Liz Salas
Jennifer Thompson
JuJu James
Kaci Griffin
Khye Tyson
Kiera Hereford
Lo Bullock
Mckenzie Mitcham (MAC)
Michelle Singleton
Passion Smith
Racquel Washington
Safira ‘SPA Doulah’ Zayas
Tiffany Bellfield El-Amin
Vanya Francis
Whitney Williams-Black
Please select your top 3 choices for a Maternal Mental Health Therapist
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LaCresha Cunningham, LCSW
Valerie Dallas, LCSW
Valon Alford, LCSW
Whitney Coble, LCMHC, PMH-C
Mary Miller, LCSW
Please select top choices for a Lactation Support Professional
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Atalya Rajahn
Shanice Nelson
Diaper Size
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Please Select
Preemie
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
Size 7
N/A
Stroller Type
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Please Select
Standard Stroller
Double Stroller
Infant Carseat
Converdible Carseat
N/A
Carseat Type
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Please Select
Infant Carseat
Converdible Carseat
How many mamas will benefit from your request?
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How many babies will benefit from your request?
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Please check all identities that apply to the parent(s) and baby or babies who will benefit from this request.
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Mama
Nonbinary, trans, or gender non-conforming
Papa
Solo parenting
College student
High school student
Under 21
LGBTQ or queer
Houseless or housing insecure
Food insecure
Low wage worker
Unemployed
Disability - parent
Disability - baby
HIV/AIDs
In recovery
Sex worker
Immigrant or refugee
Not fluent in English
Domestic violence survivor
Mental health issues
Incarcerated parent (or in conflict with the law)
None of the above
Other relevant identity
Please use this space to explain any of your responses above, if relevant.
We Want to Hear Your Story. In this section share your story relating to your current circumstances. Please use full sentences and provide as much information as possible concerning your request (i.e. "I am a single mom of three and was recently laid off in March due to COVID-19. I am requesting funds to help...") as this information is used for application consideration.
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In effort to bring more awareness and support to the BJ Care Fund, it can be helpful to share details of your story with our funders and/or social media campaigning. Do you consent to allowing our team to share your story without using your name?
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Please Select
Yes
No
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