Doula Training Scholarship Application
Presented by Capital Area Healthy Start Coalition and Sunshine Health
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / 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 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
Other
Please upload your Resume:
*
Browse Files
Drag and drop files here
Choose a file
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of
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?
*
Yes
No
If yes, ages?
*
Do you know anyone who works for Capital Area Healthy Start Coalition?
*
Yes
No
If Yes, please provide their name:
*
Are you interested in becoming a Certified Doula?
*
Yes
No
Do you have reliable transportation?
*
Yes
No
Can you pass a Level II background Screening?
*
Yes
No
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 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 medical facilities you provide Doula services require this vaccine?
*
Are you CPR Certified?
*
Yes
No
If yes, please provide dates valid: (a copy of the card will be required)
*
Are you currently employed?
*
Yes
No
If yes, please list employer and employment status(full time, part time, etc.):
*
What Ethnicity do you identify as?
*
Hispanic
Non-Hispanic
Prefer not to say
What Race do you identify as?
*
White
Black
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Prefer not to say
Other
Are you legally authorized to work in the United States?
*
Yes
No
Electronic Signature
*
Date
*
-
Month
-
Day
Year
Date
Questions or comments?
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