The Peaceful Presence Project : End-of-Life Doula Compassion Funds Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete the following application for Compassion Funds from The Peaceful Presence Project. Once approved for Compassion Funds, applicants must complete a background check and submit a W9 form and proof of insurance to TPPP. Invoices are to be sent monthly to Kari Sims Anthon, Program Manager, who will be your main point of contact kari@thepeacefulpresenceproject.org.

Funds are available to end of life doulas working with clients in the following Oregon Counties:

Crook, Jefferson, Deschutes counties with funding from the Rosendin Foundation.
Coos, Deschutes, Douglas, Jackson, Josephine, Klamath and Lane counties with funding from the Cow Creek Umpqua Indian Foundation.

* The Peaceful Presence Project is able to compensate up to 30 hours at $35/hour per client upon acceptance of your application and completion of your required paperwork

Your Name

Email Address

Telephone Number

What identified Oregon county do you live and work in? (select from dropdown)

Where did you complete your End-of-Life Doula Training? Are you a NEDA Proficient EOL Doula?

I am a graduate of The Peaceful Presence Project Professional Training Program through a Facilitated Cohort

I am a graduate of The Peaceful Presence Project Professional Training Program through the Self Paced Program

I am a graduate of The Peaceful Presence Project Professional Training Program, Rural Oregon Focused

I am a graduate of an outside End-of -Life Doula Training (please list details of program under "Other")

I am a NEDA proficient EOL doula

Other:

Please explain the current client situation for which you are applying for Compassion Fund support (where is the client located, diagnosis/prognosis, social/environmental/family situation, why they currently require financial assistance for EOLD support, and any additional information you feel would be helpful to understand the clients' current needs):

Please tell us about your engagement plan for working with this client as an EOLD:

How many hours do you anticipate working with this client? (TPPP is able to compensate up to 30 hours at $35/hour per client)

Please list any previous experience you have working with individuals at the end of life, in either a personal or professional capacity:

By writing my name below, I agree and understand that if selected, I will need to complete a background check, complete a W9 tax form, submit proof of current insurance listing TPPP as an additional insured, and submit monthly invoices to TPPP for reimbursement:

Is there anything else that you would like us to know about your interest in working alongside The Peaceful Presence Project utilizing our Compassion Funds?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of The Peaceful Presence Project. Report Abuse

Forms