Holistic Full Spectrum Doula Hybrid Training Form
Segulah Wholistic Center
What program are you planning to enroll with?
Holistic Full spectrum Doula Full Course
Hands-0n 4 day Training Refresher Only* (for Certified Doulas)
About My Business (Birth Worker Business Course)
Holistic Postpartum Doula Course
Student Information
Student Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Phone Number
*
Email Address
*
example@example.com
Please upload your recent photo doesn't have to be professional but, mindful!
*
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Does the student have any disabilities, illness, medical conditions, personal problems, etc. that can affect his/her virtual classes/study?
*
I am an adult (18 years above)
I am a minor (16 years-17 Years)* Please email segulahwholisticcenter@gmail.com and fill out Parent/Guardian details
Parent/Guardian Details
Parent/Guardian Name
First Name
Last Name
Phone Number
Relationship
*This section is optional. You may leave it blank if it is not applicable. For certified Doulas.
*How long have you been a doula?
*Where did you train? (Certifying entity name)
*Why do you want to train with SWC?
*What's your philosophy about birth? Why did you choose to be a doula? What do you hope to gain from SWC?
*If you have any awards, recognition, certificates, please share them here:
Other Questions
How did you learn about this virtual course?
Facebook
Twitter
Instagram
YouTube
Search Engine
Online Ads
Referral
Other
What is your passion about becoming a doula?
*
Any additional comments or information you would like to share?
Student Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Which Cohort are you applying for?
Winter
Spring
Summer
My Products
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Early Bird Certified Holistic Doula
$
1,000.00
Quantity
Price
1 time full payment
1
2
3
4
5
6
7
8
9
10
$
1,000.00
3 months deposit
1
2
3
4
5
6
7
8
9
10
$
300.00
1 time discount full payment
1
2
3
4
5
6
7
8
9
10
$
850.00
Early Bird Postpartum
$
875.00
Quantity
Price
1 time Full payment
1
2
3
4
5
6
7
8
9
10
$
875.00
3 month deposit
1
2
3
4
5
6
7
8
9
10
$
200.00
Minding My Doula Business/Retreat only
$
575.00
Quantity
Price
1 time Full Payment
1
2
3
4
5
6
7
8
9
10
$
575.00
3 month deposit
1
2
3
4
5
6
7
8
9
10
$
175.00
Payment Methods
Credit Card
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
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