Birth Support Scholarship
it's important to note that this opportunity is not limited to those in financial hardship only. Our work is very emotional and we encourage anyone to submit an application if they feel like a doula is unattainable for any reason.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently pregnant?
Yes
No
Are you filling out the form for your self or nominating someone you know?
Please Select
Self
Someone I know
What is the Estimated Due Date of the person applying for this scholarship?
-
Month
-
Day
Year
Date
Where is the expected location of planned Birth?
Please check all that apply
Single mother
Black, African American, or Hispanic/Latina
Teen
Planning to birth without support person
LGBTQ
Military (spouse not present at Birth)
High risk
Other
Are you able to pay a portion of the fee for Birth Support? (Sliding scale $550-$850) If so how much?
Why do you or someone you are nominating desire a Doula?
Is there any complications , risks or special needs associated with this pregnancy, Birth plan or postpartum healing?
Is there anything else you would like me to know about yourself, the person you are nominating, pregnancy or Birth desires?
Confidentiality Notice
All information provided in this application will be kept strictly confidential. It will only be used for the purpose of assessing your eligibility for sliding scale fees and will not be shared with any third parties without your consent.
Agreement
By submitting this application, you agree that the information provided is accurate and reflects your current financial situation.
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: