CPHW Application

Birth Strides

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Birth Strides Community Perinatal Health Worker Application

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Birth Date *

MM/DD/YYYY

Street Address *

City *

State *

Zip Code *

Applicants must live within one of neighborhoods served.

Are you currently employed? *

Yes, Full-Time Yes, Part-Time No, I'm a student No, I'm unemployed

If currently employed, please list your occupation *

Education Level *

Some High School Completed High School Some College Associate's Degree Bachelor's Degree Master's Degree PhD

Total household Income *

Unemployed $1-$15,000 $15,001-$30,000 $30,001-45,000 $45,001-$60,000 $60,000 +

Do you have children? *

No Yes, 1 Yes, 2 Yes, 3 or more

What is your availability to work with clients post training? *

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? *

Yes No Unsure

Are you able to attend 1-2 births per month *

Yes No Unsure

Do you have prior birth experience? *

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? *

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) *

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

Home
About
- Meet the Team
Programs
- Doula Services
- Community Perinatal Health Worker Training
Doula Request
Contact
Blog
Donate