MAMANANDA Birth Circle
Free Childbirth Education Class + Doula Support Application Form
You can follow us on instagram @mamanandabirthcircle
email us your questions at mamanandabirthcircle@gmail.com
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Estimated Due Date
*
/
Month
/
Day
Year
Date Picker Icon
What number of pregnancy is this
How many weeks pregnant are you
Where do you plan to have your baby?
*
Hospital
If at home, What Midwife
City
State / Province
Postal / Zip Code
Do you have any of the following risk factors (check all that apply):
Asthma
Sickle Cell
Diabetes
HIV
Hypertension
Anemia
Other
Are you dealing with any of the following challenges:
Houselessness
Lack of social support
Alcoholism
Substance Abuse
Lack of Medical Care
Unemployment
Lack of Transportation
Are you currently receiving any of the following:
*
WIC
Energy Assistance
SNAP
Housing Assistance
TCA
Unemployment Benefits
I am not receiving any of these benefits
Are you currently taking any medication?
Yes
No
Please list them.
Do you have Maryland Medicaid?
*
Yes
No
Do you have an MCO?
*
Please Select
Wellpoint
Aetna
Kaiser
Jai Medical
United Health
Blue Cross Blue Shield
Other
I don't have Medicaid
These are the following dates of the Mamananda Birth Circle. Please indicate which classes you are able to attend. Priority will be given to those who are able to attend all sessions. Please share your availability in honesty and integrity.
*
April 14th
April 21st
April 28th
May 5th
Can you briefly describe some of your birthing goals?
(example: unmedicated, peaceful, etc.)
Are you interested in having a doula at your birth?
*
Are you interested in having a midwife attended homebirth?
Have you taken a childbirth education class before?
Yes
No
Can you share with us why you would like to take the Mamananda birth circle class and how you think it will impact your pregnancy and birth?
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The following questions are for research purposes:
What is your monthly income level?
*
How much schooling have you completed?
*
Please Select
High School
High School Equivalent/GED
Some College
College
Do you feel like your income level and amount of schooling has an impact on your birth experience?
*
What is your race?
*
Complete!
Thank you for completing the application for the Mamananda Birth Circle Spring 2024. Please feel free to reach out with any questions to mamanandabirthcircle@gmail.com. Notification of acceptance into the childbirth education program will be sent out on April 1st 2024. Acceptance is based off of need adn ablity to commit to the class.
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