G.R.O.W. Doula Scholarship Application
Name
First Name
Last Name
Email
example@example.com
Age
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
What Race do you identify as?
What Ethnicity do you identify as?
Are you a Medicaid recipient?
Please Select
Yes
No
Do you have any children?
Please Select
Yes
No
If yes, How many?
Highest level of education:
List of community activities and/or previous volunteer work in the community:
How long have you lived in this community?
Language(s) in which you are comfortable providing services:
Do you plan on relocating?
Please Select
Yes
No
Do you have any maternal-child health experience? If so, provide details.
Share why this training is important to you?
Are you interested in becoming a Certified Doula?
Please Select
Yes
No
Do you know anyone who works for Indian River County Healthy Start? If yes, who?
Estimated household income?
Do you have reliable transportation?
Please Select
Yes
No
Understanding the time commitment, how many births are you willing to commit to assisting women in the community within the year? (This includes being on-call and available 24 hrs/day for those women as they approach their due date.)
Have you completed & passed a Level II background screening within the last 5 years?
Please Select
Yes
No
If no, would you be willing to undergo a Level II background screening in accordance with local laws/regulations?
Please Select
Yes
No
Have you received the flu vaccine? If yes, would you be willing to provide proof of vaccine? If no, would you be willing to receive the vaccine if medical facilities you provide Doula services require this vaccine?
Have you received the COVID-19 vaccine? If yes, would you be willing to provide proof of vaccine? If no, would you be willing to receive the vaccine if medical facilities you provide Doula services require this vaccine?
Are you employed?
Please Select
Yes
No
If yes, please list employer and employment status(full time, part time, etc.):
Job Title:
Start date:
Employer’s address:
Employer’s Phone number:
Are you CPR Certified? If yes, please provide dates valid? A copy of the card will be required.
Are you legally authorized to work in the United States?
Please Select
Yes
No
Electronic Signature:
Date:
Questions or comments?
Submit
Should be Empty: