BIRTH STRIDES
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Birth Strides Community Perinatal Health Worker Application
*
Indicates required field
Name
*
First
Last
Phone Number
*
Email
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Birth Date
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MM/DD/YYYY
Street Address
*
City
*
State
*
Zip Code
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38106 (South Memphis)
38107 (North Memphis)
38108 (North Memphis)
38109 (Whitehaven/Westwood)
38111 (Orange Mound)
38112 (Binghampton)
38114 (Orange Mound/ Glenview)
38116 (Whitehaven)
Applicants must live within one of neighborhoods served.
Are you currently employed?
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Yes, Full-Time
Yes, Part-Time
No, I'm a student
No, I'm unemployed
If currently employed, please list your occupation
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Education Level
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Some High School
Completed High School
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
PhD
Total household Income
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Unemployed
$1-$15,000
$15,001-$30,000
$30,001-45,000
$45,001-$60,000
$60,000 +
Do you have children?
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No
Yes, 1
Yes, 2
Yes, 3 or more
What is your availability to work with clients post training?
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4-6 hours per week
6-10 hours per week
10-12 hours per week
12-15 hours per week
15 + hours per week
Do you have the ability to be on call for births and provide continuous support for an indeterminable time period?
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Yes
No
Unsure
Are you able to attend 1-2 births per month
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Yes
No
Unsure
Do you have prior birth experience?
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Yes, I have attended at least one birth other than my own
Yes, I have experienced childbirth
No, I have no prior birth experience
Do you have home visitation and/or case management experience?
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Yes, I have case management experience
Yes, I have home visitation experience
Yes, I have home visitation and case management experience
No, I do not have experience in home visitation or case management
Are you a currently trained birth worker? (Check all that apply)
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No
Doula
Midwife
Childbirth Education
Breastfeeding/Lactation Counselor
If applicable, please list any health related trainings, degrees, or certifications and dates completed
*
What are your goals for becoming a Community Perinatal Health Worker?
*
Submit
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