BetterBirth University Doula Application
To apply for a doula placement, you must submit the following:

1) This application.
2) A photocopy (may be scanned and e-mailed) of your doula training completion certificate.
3) Non-refundable application fee of $20.
4) Non-refundable background check fee of $20. Does not apply if we completed a background check for you within the past 18 months.
For fees and tuition you may send a check to BetterBirth, 230 W 170 N, Orem UT 84057 or you may call (801) 225-5668 and pay by credit card over the phone.

Keep in mind that during your placement, you will be expected to attend all births to which you are called from the time you are requested by the client to 1 hour postpartum.
Full Legal Name *
Enter Last, First Middle
Street Adress *
Enter the street portion of your mailing address.
City *
Enter the city of your mailing address.
State *
Enter the state (or province) of your mailing address.
Zip or Postal Code *
Enter the zip code or postal code of your mailing address.
Country *
Enter the country of your mailing address.
Home Phone
If you have a land line, enter it here.
Cell Phone
If you have a cell phone, enter it here.
Other Phone
If there is another phone number you would like us to use to reach you, enter it here.
E-mail Address *
Enter your e-mail address VERY CAREFULLY!
Planning to Certify? *
If you are planning to certify as a doula, please check the organization(s) below whose certification you are seeking.
Required
When did you take your doula training? *
Enter the month and year of your doula training class.
I hereby grant permission to BetterBirth, LLC or its agent to conduct a criminal background check on me. *
Entering your name in the box below will serve as an electronic signature permitting us to perform the background check. We cannot process your application without the background check. If you are unwilling to permit the background check, please enter "permission not granted". If we have previously conducted a background check on you, write "See previous".
Social Security Number *
Enter your social security number.
Date of Birth *
Enter your date of birth: MM/DD/YYYY
Are you a CSM student? *
Indicate whether or not you are currently enrolled in the Community School of Midwifery.
Do you smoke? *
Indicate whether or not you smoke.
Submit
Never submit passwords through Google Forms.
This form was created inside of Better Birth. Report Abuse