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Community Care Fund Application

Thank you for your interest in the Community Care Fund. This fund exists to reduce financial barriers to doula care and prioritize support for those who face the greatest disparities in maternity care. All information shared in this application is confidential and used only to determine eligibility and funding availability.

Completion of this application does not guarantee funding. Awards are made based on available funds and community need.


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Email *
Name *
Phone number *
City/Community *
Preferred Method of Contact *
Required
Pregnancy & Care Details
Estimated Due Date or Baby's Birth Date *
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/
DD
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Type of Support Requested *
Required
Planned Place of Birth
Who is your medical provider? (doctor or midwife?)
Eligibility & Community Prioritization
Do you belong to one of the communities our fund was established to serve?
Please select any that apply to you
Financial Need
Please refer to the Green Bottle Scale shared on our website for examples of how to assess financial need.
Would the cost of doula care be a barrier for you without financial assistance? *
Do you qualify for any of the following services/programs?
Briefly share why financial support would be helpful right now (optional)
Are you able to contribute any amount toward care? *
If yes, what amount feels manageable?
Is there anything else you’d like us to know about your situation or support needs?
I understand that submitting this form does not guarantee funding and that awards depend on available funds and community need. *
Required
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