AZ Family Massage Out of Hospital Birth Scholarship

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By filling out this form and applying for this scholarship you agree to have your essay and video used in whole or in part on Websites, social media and print by AZ Family Massage, PLLC. You agree that you reside in the Phoenix metro area and you agree to hold AZ Family Massage, PLLC harmless in the event of a unexpected outcome for your out of hospital birth. If, after insurance, the client's out-of-pocket costs are less than $300, the client agrees to refund the difference between the client's actual out-of-pocket costs and $300.

What is your name?

What is your email? *

What is your phone number?

What is the best way to contact you?

Phone

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Do you reside in the Phoenix Metro Area?

Yes

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Option 1

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Do you agree to allow AZ Family Massage to use your essay or video in part or whole online or in print? *

Yes

Do you agree that you do not have a health insurance plan that will cover your entire out of hospital birth? *

Yes

“How does childbearing change your relationship with your body and how is self care part of your childbearing year?" Insert your essay answer below. If using a video submission please submit a link to your downloadable video to graceburnham@gmail.com (do not e-mail the video, just the link) and in the box below please list the file name as well as the email address it will be coming from so we can associate your video with your applications *

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