Doula Training Application - Waitlist
Please fill out the following application if you are interested in training to become a Doula, and working with Medicaid eligible mothers in Erie and Niagara County. 
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Email *
First Name *
Last Name *
Date of Birth *
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DD
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YYYY
Home Street Address *
City *
State *
Zip Code *
Contact Number (xxx) xxx - xxxx  *
Ethnicity/Race  (Check all that apply) *
Required
What languages can you proficiently speak about pregnancy & childbirth? *
Required
Do you have a high school diploma or GED? *
Are you willing to undergo a background check? *
Briefly describe your most current work role. *
How long were you employed with your most recent employer? *
Are you currently a certified Doula? If you are already certified, where did you receive your certification? *
Required
If applicable, how long have you been a Doula? *
Do you have any other relevant training/certifications as a Doula? List all trainings and certifications below. (If not applicable, indicate with N/A) *
How many live births have you attended as a 
Doula or support person? (If not applicable, indicate with N/A)
 *
What circumstances do you have experience supporting? *
Required
What attracted you to work as a Doula? Why do you want to work on the Erie Niagara AHEC Birth Equity Project in particular? *
What challenges do you (or expect to) encounter when working as a Doula? *
What makes you a strong candidate for a Doula position? *
The ability to work with our clients in their home depends on having reliable transportation. What main transportation do you anticipate using to visit our mothers and during labor & delivery? *
Required
Doulas have to be able to respond to phone calls, emails, and texts on a consistent basis. Are you able to commit to responding to different forms of communication in a reliable and reasonable amount of time? *
Do you have a cell phone that is able to receive phone calls, text messages, and email? *
How will you organize your time and efforts to meet the needs of clients and staff? Being on call is necessary for specific clients who might give birth at any time and who might experience prolonged labors. *
Are there specific hours that you would not be able to provide Doula services? (If not applicable, indicate with N/A) *
Please share any limitations/exclusions you have in providing Doula related services. *
Would you be able to commit to providing Doula services to mothers for up to a year? *
Would you be available to attend additional 1.5 hour trainings after the initial Doula training? Additional trainings include Medicaid reimbursement, billing, HIPAA, etc. If no, please indicate why in the "Other" section.  *
Required
I understand that there is a $100 commitment fee owed upon acceptance into the program. The $100 commitment fee will be reimbursed upon completion of program requirements. Further details will be provided if you are selected.  *
How did you hear about the Erie Niagara AHEC Birth Equity Program? *
Please let us know if you have any additional comments or questions here.
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