Topeka Doula Project - Postpartum Doula Scholarship Application Form
Please fill out the form below to apply for the scholarship.
Qualifications:
Must be at least 18 years old.
Have a valid Drivers License.
Access to reliable transportation
strong written and verbal communication skills.
Ability to work independently.
Ability and desire to work as a team.
Passion to be a part of building a movement for maternal health in Shawnee county.
A commitment to transform maternity care, especially for strategically underserved communities.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Annual Household Income
*
Please Select
$20,000-$40,000
$40,001-$60,000
$60,001-$80,000
$80,001+
Race
*
What is a postpartum doula?
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What is your interest/reason for joining Topeka Doula Project?
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Why do you want to become a doula?
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Back
Next
As a doula, how will you work to decrease disparities and improve maternal and infant health?
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Share why you think Doulas/ postpartum Doulas are important, and how the work relates to birth justice.
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Do you foresee the time commitment becoming an issue? Please describe how you plan to balance your time between responsibilities. (Our program is a two-year commitment and a minimum of 6 clients; along with completing your certification)
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Who is your support system?
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What do you hope to contribute to this program and the birthing community that we support?
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Are you employed?
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Yes
No
If yes; Current Employer
Does your employer know you want to become a doula?
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Yes
No
If yes, do they support your decision?
Yes
No
I haven't asked
How did you hear about the scholarship opportunity?
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How will this scholarship help achieve your goal of becoming a postpartum doula?
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Why do you think YOU should be chosen for the Postpartum doula scholarship and to become a part of Topeka Doula Project?
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References
Please provide 3 references for us to contact; at least 1 professional reference (supervisor, manager, coworker, etc.)
1. Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Relationship to you
*
2. Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Relationship to you
*
2. Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Relationship to you
*
By Signing here I acknowledge that I have answered the questions truthfully.
Signature
*
Submit
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