2026 Community Doula Training Sponsorship Application

Doula Training Scholarship Application

Presented by Capital Area Healthy Start Coalition and March of Dimes
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What professional maternal-child health experience do you have?*
Tell us WHY you want to become a Community Doula*
Highest level of education*

8th grade or lessHigh school but no diplomaHigh school diploma or GEDCollege but no degreeAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate DegreeOther
Please upload your Resume:*

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Please upload your Reference List (3 Professional References Required):*

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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 have children?*

YesNo
If yes, ages?*
Do you know anyone who works for Capital Area Healthy Start Coalition?*

YesNo
If Yes, please provide their name:*
Are you interested in becoming a Certified Doula?*

YesNo
Do you have reliable transportation?*

YesNo
Can you pass a Level II background Screening?*

YesNo
Have you received the flu vaccine?*

YesNo
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?*

YesNo
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 CPR Certified?*

YesNo
If yes, please provide dates valid: (a copy of the card will be required)*
Are you currently employed?*

YesNo
If yes, please list employer and employment status(full time, part time, etc.):*
What Ethnicity do you identify as?*

HispanicNon-HispanicPrefer not to say
What Race do you identify as?*

WhiteBlackAsian or Asian AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderPrefer not to sayOther
Are you legally authorized to work in the United States?*

YesNo
Electronic Signature*

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Doula Training Scholarship Application