Doula Volunteer Application Online Doula Volunteer Application Form I have carefully read the CCRMC Doula Program website and FAQs and understand the role as a volunteer doula at CCRMC: Full Name: Address: Telephone: Area Code first Email: Date of Birth: Applicants must be 21 years of age or older. Are you over 21 years of age?: Yes I am 21 No prior training or education is required. What is your highest education level achieved? We welcome participants of all identities and backgrounds. Which of the following best represents your racial or ethnic heritage? (select all that apply) Non-Hispanic White or Caucasian Black, Afro-Caribbean, or African American Latino or Hispanic East Asian or Asian or Pacific Islander South Asian or Indian Middle Eastern Native American or Alaskan Native Other Please list any language you speak fluently, besides English: Training/Certification: Upcoming training: January 11-12, 2020, from 8:30am-4:30pm both days. Certification: You will be granted a Certificate of Completion of your CCRMC Volunteer Doula Program once you complete the 2-day workshop and your 100 hour service commitment. How did you hear about the CCRMC volunteer Doula program? Current/Former volunteer Former Patient Staff Member CCRMC Website Contra Costa County Volunteer Center Other What is a doula? Briefly describe this role to show us you understand what this is: Why do you want to be, or why are you a doula in particular?: Why do you want to be a volunteer doula, specifically?: Briefly describe 2 or more experiences that you feel prepare you for this program specifically and why? (Tip: be specific regarding this role and setting. No prior experience is required, but if it applies, please refer to any doula, lactation or related experiences): Tell us a little bit more about yourself. You might choose to tell us about hobbies, family, something you are passionate about, etc. to help us get to know you better: We require that you complete at least 8 hours of doula service per month, with at least 4 hours scheduled ahead monthly. What supportive forces can you cite that will make it possible for you to honor your commitment? Our program communicates via Google Calendar, Gmail, and WhatsApp. Are you willing and able to use these communication methods? GENERAL INFORMATION To provide a quality volunteer program at the Contra Costa Regional Medical Center and to insure that we do our best to match the needs of the Hospital and our Volunteers, we ask a certain amount of detailed information regarding your personal and work related experiences. With this information we are better able to offer you an assignment that can be tailored to your needs as well as ours. EDUCATION: 2-Year College Completed Adult Education 4-Year College Completed Area of Study: Graduate Studies Please note any ORGANIZATION AFFILIATIONS that you have: EMPLOYMENT: Current Employment Status: County Employee Full Time Part Time On Call Retired Unemployed Employer: Address: Date Start: Date End: OTHER RECENT EMPLOYMENT: Employment Status: County Employee Full Time Part Time On Call Retired Unemployed Employer: Address: Date Start: Date End: CURRENT OR RECENT VOLUNTEER POSITIONS: 1. Title: Employer/Institution: Supervisor Name: Phone: Full Time Part Time - hours per week: Date Start: Date End: 2. Title: Employer/Institution: Supervisor Name: Phone: Full Time Part Time - hours per week: Date Start: Date End: EMERGENCY CONTACT INFORMATION: 1. Name: Contact Number: Relationship: 2. Name: Contact Number: Relationship: Do you have a health problem we should be aware of in case of emergency? Yes No (If yes, please describe - such as history of back trouble, heart, epilepsy, diabetes, fainting, etc.) Primary Care Physician: Telephone Number: Hospital: Dentist: Telephone Number: Address: REFERENCES: In order to process your application, it is essential that all information requested below is provided. References should not be from relatives. References from current or past supervisors are preferred. 1. Name: Address: Phone: Email: How do you know this person: 2. Name: Address: Phone: Email: How do you know this person: ADDITIONAL INFORMATION: Are you willing to be called to serve as a volunteer in the event of a County wide emergency such as an Earthquake or Flood: Yes No Are you doing volunteer work as an education requirement? Yes - hours required? No You are invited to join our auxiliary. Would you be interested? Yes No Would you be willing to serve in a capacity that might require patient contact? Yes No Would you be willing to push a wheelchair if needed? Yes No I understand that I am volunteering my services to Contra Costa Regional Medical Center and/or Health Centers without promise or expectation of compensation or future employment. I further agree to serve as a volunteer for a minimum of 96 hours within the calendar year. (Please check to agree/proceed.) Enter the numbers:
