SCHOLARSHIP APPLICATION FOR CERTIFICATION COURSES

SCHOLARSHIP APPLICATION FOR CERTIFICATION COURSES

Happy Mama Healthy Baby Alliance
Instructions: Complete this application and submit it electronically to be considered for a scholarship for the training. You can partially complete this form and save it to finish later – see SAVE button at bottom of form.

PERSONAL INFORMATION
Name*

First NameLast Name
Criteria for Scholarship (Please check all that apply):*

Black, Indigenous, or other person of color (BIPOC)Low-IncomeReside in California18 years of age or olderHigh School graduate or GED Completion
Please upload a photo of yourself (face only, color, with no-one else in picture):

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1) Course Applying For:*

Community Birth Doula TrainingHeart and Hands Postpartum Doula TrainingBreastfeeding Peer Counselor TrainingMidwife Assistant Course
2) Month and year of course:
3) What is your Age Group?*

18-2324-2930-3536-4041-4647-5253-5960-6565+
4) Gender Identity:*

FemaleMaleTransgender FemaleTransgender MaleNon-Binary
5) Email*
example@example.com
6) Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
7) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
8) Race (Choose one):*

HispanicNon-Hispanic
9) Ethnicity (check all that apply):*

Black/African AmericanWhite/European/CaucasianLatine/Latina/Latinx/LatinoAsian/Asian Pacific IslanderNative American/American Indian/Alaskan NativeOther
10) Languages Spoken Fluently (include English): *
11) Are you currently employed?*

YesNo
If yes, what is your current occupation?
Monthly Net Income:
12) Current Sources of Income:*

WagesUnemploymentGeneral ReliefDisabilitySelf-EmploymentStudent Financial AidOther
13) Are you currently receiving public assistance, such as Cal Fresh, or Medi-Cal, Cal Works, or General Relief?*

NoYes (attach photo proof i.e., Medi-Cal card; EBT card, etc.)
14) File Upload

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15) Are you currently a student?*

YesNo
If enrolled in school, where do you attend?
What is your major/minor?
Anticipated Graduation Date:
Degree Pursuing (Certificate, Associate, Bachelor, Masters, etc.):
Tell Us About Yourself and Your Desire to Become a Doula
16) Do you have any certifications or training in Perinatal Health? Click all that apply:

Birth DoulaPostpartum DoulaLactation Educator or CounselorBreastfeeding Peer CounselorChildbirth EducatorMental Health/CounselingFamily Planning/STDsOther
17) Why do you want to become a doula?*
18) What key skills and qualities or experiences do you feel you have that will help you shine as an effective doula, especially for underserved populations? Feel free to share your unique strengths—whether emotional, intellectual, or practical—that you believe will empower you to be a passionate advocate and be a reliable support system for moms as a doula.*
19) Have you encountered any personal challenges or experiences that have inspired your journey to become a doula? We’d love you to share your story. Think about any life events, difficulties, or meaningful moments that have fueled your passion for this path. You’re welcome to include any financial, social, or personal hurdles that have played a role in your motivation!*
20) Have you or someone you care about ever faced racial discrimination in the healthcare system, particularly in maternity care? If so, we’d love to hear about your experience or that of someone close to you. How did this situation affect you, and what steps were taken afterward?*
21) What differences or inequalities exist in maternal healthcare for Black and Brown communities? Share your thoughts on how race affects the quality of care and outcomes for women in hospitals and other healthcare settings.*
22) What are your thoughts on how a doula can help fight against racial discrimination and foster equity in healthcare? We’d love to hear your ideas on how doulas can play a key role in reducing bias and enhancing maternal health outcomes for disadvantaged communities.
23) Upon completion of your doula training, how do you plan to give back to your community? Share specific ways you hope to use your new skills to make a difference in maternal health care in your community.*
24) Our organization requires electronic documentation of prenatal and postpartum visits and birth attendance with mothers. Are you computer savvy in Outlook email and calendar, SharePoint, Word, and have a computer, internet access, so are you capable of completing computerized paperwork by deadlines?*

YesNoNo, but I'm willing to learn.Maybe, I need more information and help.
25) Do you have reliable transportation accessible to you to attend appointments and/or births with clients?*

YesNo
26) Are you available to be "on-call" 24/7 days a week (including holidays) to attend births?*

YesNo
Terms and Conditions

1. By accepting this scholarship, I agree to attend every training session for the entire time and participate fully.

2. I agree to participate in HMHBA’s certification program and meet all deadlines.

3. By accepting this scholarship, I agree to volunteer for HMHBA for three (3) births/families to obtain certification. (During this time, we will assist you with becoming Medi-Cal credentialed. Upon certification, you may join our team if desired, or choose to work on your own, with other doula organizations, and/or with HMHBA).

If you agree to these terms and conditions, add your signature below.
Signature*
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