Doula Training Scholarship Application
Please complete the form below to apply for a community doula scholarship. Our doula scholarships provide complete coverage for a comprehensive 3-day course, a level 2 background screen, and CPR training. Applications for doula scholarships can be submitted no later than June 20th at 11:59 p.m. After completing the application, applicants will be contacted to register for a mandatory information session before scheduling interviews.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
What Race do you identify as?
White
Black
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Other
What Ethnicity do you identify as?
Hispanic
Non-Hispanic
Are you a Medicaid recipient?
Yes
No
Do you have children?
Yes
No
If yes, how many?
Highest level of education
8th grade or less
High school but no diploma
High school diploma or GED
College but no degree
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
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?
Yes
No
Do you have any maternal-child health experience?
Yes
No
If so, provide details.
Share why this training is important to you.
Do you know anyone who works for Capital Area Healthy Start Coalition?
Yes
No
Estimated household income.
Are you interested in becoming a Certified Doula?
Yes
No
Do you have reliable transportation?
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 hours/day for those women as they approach their due date.)
Have you had a Level II background screening within the last 5 years?
Yes
No
If no, would you be willing to undergo a Level II background screening in accordance with local laws/regulations?
Have you received the flu vaccine?
Yes
No
If yes, would you be willing to provide proof of vaccine?
If no, would you be willing to receive the vaccine if the medical facilities you provide Doula services require this vaccine?
Have you received the COVID-19 vaccine?
Yes
No
If yes, would you be willing to provide proof of vaccine?
If no, would you be willing to receive the vaccine if the medical facilities you provide Doula services require this vaccine?
Are you currently employed?
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?
Yes
No
If yes, please provide dates valid: (a copy of the card will be required)
Are you legally authorized to work in the United States?
Yes
No
Electronic Signature
Date of signature:
Questions or comments?
Continue
Continue
Should be Empty: