Address:
City:
State:
Zip Code:
County:
Phone:
Email:
Check all that apply:
___ Teen mom
___ Single mom
___ Low income
___ Student: type or major _________________________
___ Mother
Racial/ethnic group(s):
___ African-American
___ Arabic
___ Asian
___ Caucasian
___ Hispanic
___ Native American
___ Multi-racial
___ Other (please specify) _________________________
Languages spoken, other than English (please indicate level of fluency):
___ Spanish
___ Arabic
___ American Sign Language
___ Other (please specify) _________________________
Please answer the following questions.
1. Why do you want to be a postpartum doula?
2. Do you have children yourself?
3. If you have children, did you breastfeed? Can you tell us about your experience with breastfeeding?
4. If you do not have children, have you had any experience working with newborns? Tell us about it.
5. Have you had any experience assisting families in the early weeks postpartum?
6. Have you read any books on the subjects of pregnancy, natural childbirth, breastfeeding, parenting, etc.? Please list.
7. Where do you see yourself in 3-5 years?
8. Will you be able to attend every session of the training?
9. Do you intend to fulfill all of the requirements towards Postpartum Doula Certification? (Please visit www.DONA.org for more information on doula certification requirements.
10. The Doulas Care Program is a volunteer program that helps student doulas gain experience at births by matching them with low income, at risk women who could use some extra support during their pregnancy, birth, and postpartum but can't afford to hire a doula. The Center is beginning to pilot a postpartum piece to this program as referrals have begun to come in for under-supported, low-income women in fairly desperate circumstances. Volunteer work must be completed within 18 months of completing the training. Do you believe it is realistic for you to commit to providing 50 hours of free postpartum services to families in need? If your ability to volunteer as a doula is limited for any reason (i.e., childcare concerns, transportation limitations, current pregnancy), please explain.
11. What is your comfort level or experience in working with a culturally diverse population of women with limited resources?
12. Where or from whom did you hear about this program?
13. How important is this scholarship to you in order for you to become a postpartum doula?
14. Is there anything else you would like us to take into consideration when reviewing this application?