CU Birth Fund Interest: Midwife or Doula

Thank you for your interest in working with the CU Birth Fund.

The CU Birth Fund will help pay for doula and homebirth midwife services for pregnant people of color in East Central Illinois. By offering extra support during pregnancy and birth, the fund will help improve care for these families and support more positive birthing experiences in the Black, Indigenous, People of Color (BIPOC) community.

If you provide these services, and are interested in getting involved, please complete the following form:

First name

Last name

Email

Phone

Website url

Type of services provided:

Midwifery services

Doula services

Other

Please describe your services: (For example: full spectrum doula services, prenatal doula services, postpartum visits, homebirth midwifery, lactation consultation, etc.)

Have you attended a birth before?

If yes, how many?

Do you have a certification?

If yes, through what organization(s)?

What is the estimated cost of your doula and/or midwifery services?

Do you provide services and support in a language other than English? If yes, please specify which language.

Additional Information: Please share any other information you think is important for us to know (optional)

Email consent

I consent to be added to the UCRJ/CUB Fund email list.

I do not consent to be added to the email list.

Consent and Agreement

I certify that the information provided is true and accurate to the best of my knowledge.

I consent to the use of my data for the purposes of this application.