Name:

Address: 

Phone Numbers:

     Home Phone: 

     Cell Phone: 

     Work Phone: 

Email: 

Name, Dates & Location of Doula Training Workshop: 

Are You Certified?  Yes No         

If working towards certification, when do you anticipate completion?: 

What areas are you willing to work in?:

       Marin

       San Francisco

       San Mateo

       Santa Clara

       Alameda/East Bay

       Contra Costa

Are there areas/hospitals you prefer to work in?  :

Are there areas/hospitals you prefer NOT to work in?  :

Do you speak any languages other than English? If so, which? 

List number of months or number of births you plan to work within the BABA volunteer doula program?  

Do you agree to: (Please mark Y or N)

 1) BABA Standards of Practice? Yes No

 2) Become a member of BABA? Yes No

 3) Provide BABA with doula workshop or certification documents within 2 weeks time? Yes No

 4) Complete and return BABA evaluation forms within a timely manner (2 weeks)? Yes No

 5) Be on call 24/7 for your client? Yes No

 Within reasonable limits, do you agree to:

 6) Contact your mentor within 48 hours of her initial call? Yes No

 7) Attend the entire birth with your mentor, assisting her as she requests? Yes No

 8) Accompany your mentor on a prenatal and postpartum visit? Yes No

Do you plan to become a professional private-hire doula? Yes No

How did you hear about BABA?