Flagstaff Birth Support Fund Application for Services

APPLICATION FOR SERVICES

Applicants First name

Applicants Last name

Applicants prefered pronouns

Phone

Address

City

State

Zip Code

Estimated Due Date

Month

Day

Year

Provider/OBGYN or Midwife

What type of support are you interested in?

We offer childbirth education, birth doula and postpartum doula support

Number of Dependents

Does pregnant person have health insurance?

Yes/No and what type of insurance

If you have insurance do you currently have any fund in an HSA or FSA?

Do you receive state, tribal, county, or federal assistance? Please list the type and amount of assistance you receive each month.

monthly gross income combined if partnered

Do you rent or own home?

Monthly Rent or Mortgage Payment

Monthly Utility Payments

Total monthly payments towards debt obligations including house, car, credit card debt, student loans.

Estimated total monthly household expenses $ (excluding rent and utilities)

Why are you intetested in support from Flagstaff Birth Support Fund

Race/ethnicity