Doula, Breastfeeding Counselor, Volunteer Application
I would like to offer my services as a:
*
Birth Doula/Childbirth Companion
Postpartum Doula
Lactation Educator Counselor
Childbirth Educator
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Certifications and Licenses (ie. Childbirth Educator, Postpartum Doula, Lactation Counseling)
If you are not certified yet, please list the name of the organization where you took your training, the date of the training(s) and the instructor
Name of Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Instructor’s Name
First Name
Last Name
Instructor's Email
example@example.com
Instructor's Website
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Attach a resume that includes your educational background and experience (if any) working with pregnant or parenting women, babies, and toddlers. (pdf file format preferred)
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Make sure to list dates and agencies where you volunteered or worked.
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What is Your Age? Select one:
18-23
24-29
30-35
36-41
42-59
60+
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Optional
What is your race?
Hispanic
Non-Hispanic
Ethnicity (please check all that apply):
African American/Black
Asian/Asian Pacific Islander
Latinx
White/Caucasian/European-American
Alaskan Native/Native American
Country of Origin (if applicable)
Other Languages/Dialects Spoken Fluently:
Do you identify as LBGTQIA+? (We will match you with clients requesting LBGTQIA+ Doula.)
Yes
No
Special Skills (aromatherapy, massage, etc.):
Number of children you have and their ages and briefly describe their births (c-section, epidural, etc.):
Experience as a Doula
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Please attach copies of two client evaluations or letters of recommendation.
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Evaluations from the parents, nurse, doctor, or midwife also accepted.
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Did you fill out a Birth Self-Report? (If so, please attach copies for two births.)
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Please describe why you want(ed) to become a Doula and/or Breastfeeding Peer Counselor/Childbirth Educator and why you want to work with Happy Mama Healthy Baby Alliance:
Do you have Doula liability insurance?
Yes
No
Name of Insurance Company & Policy Number:
Please write how you would like your profile to appear on our website:
Name
First Name
Last Name
Phone Number
If you do not want your personal number listed, apply for a Google Voice number (free of charge).
Format: (000) 000-0000.
Personal Website:
Credentials (CD, CLE, etc.):
Services Provided (Labor support, lactation counseling, Reiki, etc.):
Please attach a color photo jpeg, portrait orientation, just your head and shoulders, against a grey or white wall with no other persons in photo.
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Permissible file extensions: jpeg, jpg, png, pdf, gif
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Geographical areas you are willing to serve:
Los Angeles County
Lancaster/Palmdale
Riverside County
San Bernardino County
San Diego County
Ventura County
Other
Description of your philosophy, training, certifications, experience, education, services offered etc. (will appear on website); if you speak more than one language, please complete an English version and the other language version:
We will also send you instructions on how to record a video bio for our website.
Do you have any training or personal experience with the following:
Rows
Self
Family/Friends/Clients
Training/Education
Domestic Violence
Substance Abuse/Recovery
Sexual Abuse or Incest
Multiple Births (twins, triplets)
Preterm Labor/Bedrest or Premature Birth
C-section/Vaginal Birth After Cesarean
Infant Loss (death, miscarriage, abortion)
Teenage Pregnancy
LGBTQIA and Gender-Non-Conforming Families
Interracial Families
African-American/Black Families
Hispanic/Latino Families
Native American/American Indian Families
Asian/API Families
Perinatal Mood and Anxiety Disorders (PMADs)
Other (Specify):
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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