Birth Justice Care Fund Application
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  • Birth Justice Care Fund Application

    The Birth Justice Care Fund was originally a SisterSong Birth Justice Team needs-based initiative, for Georgia, Kentucky, and North Carolina residents, in response to the social crisis that communities of color are experiencing more critically due to the COVID-19 Pandemic and the U.S’s High Black Maternal Mortality Rate. The relief funds are intended for Black and other birthing people of color, especially Queer and Trans folks in need of support during their pregnancy and within one year postpartum. The Fund is now open and available for residents of Georgia, Kentucky, North Carolina, and Florida.

  • Please note, the Birth Justice Care Fund does not provided money directly to the applicant. The support we provide will come in the form of a birthworker/service provider or items.

  • Are you applying on behalf of someone else?*
  • If so, why?*

  • The Care Fund only allows you to apply on behalf of someone else if that person has a disability, is temporarily incapacitated, or cannot access the application. You selected that none of those are true for you, but you can still assist the person you intended to by sharing this application with them, so they can fill it out for themselves at https://www.sistersong.org/directory

     

    Thank you for your interest in the Birth Justice Care Fund. 

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  • Format: (000) 000-0000.

  • The Birth Justice Care Fund currently only considers applicants in the following states: Kentucky, Georgia, North Carolina, and Florida. 

    Please keep a lookout on our website for future updates and offerings. https://www.sistersong.net/bjcarefund

  • What language are you completing this form in?*
  • Race/Ethnicity of Applicant*
  • Race/Ethnicity of Baby*
  • What is your household income?*
  • Do you receive any of the following public assistance?*
  • How did you hear about the BJ Care Fund?*
  • What support are you requesting?*

  • If you’re looking for services and aren’t sure who to choose, we invite you to explore our Birth Justice Care Fund Directory: https://www.sistersong.net/directory Click on your state to learn more about our partners and find someone who feels aligned with your needs.

  • Do you have insurance?*

  • We will not be providing breast pumps to those with insurance. Please check with your insurance provider on how to recieve a free breast pump.

  • If you do not currently have health insurance and are seeking coverage for maternity or birthing services, please contact Madisyn Saintamand at 943-291-1513. She can assist you in exploring free and low-cost healthcare options and help determine your eligibility for coverage. Assistance is available to help you get qualified as quickly as possible.

  • Please note we will only be providing your top 3 item choices.

  • Please indicate which SERVICES you need*
  • Please select your top 3 choices for a Birth Doula*
  • Please select your top 3 choices for a Postpartum Doula*
  • Please select your top 3 choices for a Full Spectrum Doula*
  • Please select your top 3 choices for a Fertility Doula*
  • Please select your top 3 choices for a Loss & Bereavement Support Doula*
  • Please select your top 3 choices for a Maternal Mental Health Therapist*
  • Please select top choices for a Lactation Support Professional*
  • Does the applicant identify as either of the following options:*
  • Please check all identities that apply to the parent(s) and baby or babies who will benefit from this request.*

  • Release from Liability

  •       SisterSong Inc. (“SisterSong”), through its Birth Justice Care Fund, pairs award recipients (“Recipients”) with doulas, mental health therapists and/or lactation consultants (hereafter “Service Providers”) who provide doula, mental health and/or lactation consulting services on to Recipients. I, * understand that SisterSong is solely responsible for funding the services of the Service Providers on behalf of Recipients.

    By accepting my award of funds (which I understand shall be paid by The Birth Justice Care Fund directly to the Service Provider), I hereby agree to and acknowledge the following:

    1. In connection with my selection as a Recipient of an award from the Birth Justice Care Fund, SisterSong does not, and has no obligation to, vet or screen the qualifications of any Service Provider with whom I am connected. SisterSong merely populates a list of Service Providers who are willing to provide services to award recipients of the Birth Justice Care Fund. It is my decision alone whether I decide to engage the services of a Service Provider.
    2. It is my sole responsibility to interview and screen any Potential Service Provider to confirm that I am comfortable with the qualifications of my Service Provider. If I am not comfortable with the qualifications of my Service Provider, it is my obligation to immediately notify SisterSong so that they can determine whether there is any other Service Provider available to provide me with services in connection with my award. SisterSong does not guarantee the availability of any Service Provider.
    3. I hereby waive, release, discharge and covenant not to sue SisterSong, its shareholders, directors, managers, officers, agents, employees or representatives (collectively, the “Releasees”) from any and all losses, liability, claims, demands, damages or expenses (collectively, the “Losses”), which I may have, or which may accrue to my heirs, administrators, personal representatives, executors or assigns, that I may claim to have been caused by, involving or arising from the use of the services of a Service Provider funded through funds awarded by the Birth Justice Care Fund. My sole remedy for any losses shall be against the Service Provider.
    4. I agree to indemnify, save, defend and hold harmless each of the Releasees from and against any and all Losses that arise out of, or related to or result from the services of the Service Provider, or the use of funds from the Birth Justice Care Fund. I understand Service Provider will be issued a 1099 form for tax reporting purposes. This issuance does not imply nor establish any contractor relationship between SisterSong and Service Provider.


    I hereby acknowledge that SisterSong has a limited role pursuant to the description of tasks outlined above. I acknowledge that SisterSong makes no warranties regarding the qualifications or responsibilities of the Service Provider and that I have the responsibility to warrant the Service Provider’s capabilities. SisterSong has not represented to me that contracting for a doula, mental health therapist or lactation consultant services guarantees in any way a risk-free or emergency-free labor, therapy session and birth experience, or a birth and/or breastfeeding experience that fulfills all of my desires and expectations. I understand that my Service Provider may provide me with support and information but does not make medical or nursing decisions on my behalf, including decisions about when to seek medical care at a
    hospital when labor support, therapy session or lactation services are provided in my home. When doula, mental health therapist or lactation services are performed by my Service Provider while I am in a medical facility, I acknowledge that SisterSong is not responsible for the performance of the medical facility and those who work there, or the decisions they make. This includes clinical tasks, communications, medical treatments, and interactions between my Service Provider and medical facility representatives, including whether the medical facility will allow my Service Provider to accompany me. I further acknowledge that the failure of the Service Provider to provide services poses no liability for SisterSong.

    If any portion of this Release is held to be invalid, the balance, notwithstanding, shall continue in full force and effect. This Release shall be governed by and construed in accordance with the laws of the State of Georgia. This Release, and the obligations of the undersigned hereunder, shall not be affected by the knowledge of SisterSong or any other Releasee.

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