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Jofa S.A.F.E. Plan: Peer Access Network Form
Name
(Required)
First
Last
Please confirm that you are 18+ years old:
(Required)
Yes
No
Preferred Email Address
(Required)
Phone Number (Best Phone Number to Contact You)
(Required)
City of Residence
(Required)
State of Residence (Please Provide Abbreviation)
(Required)
I am interested in lending my expertise to the S.A.F.E. Plan Abortion Access Network as: (Please Check All That Apply)
(Required)
Clergy
Health Care Professional
Mental Health Professional
Community Leader
Concerned Community Member
Lived Experience/Peer Support
Other
There are growing local support networks in Orthodox Jewish synagogue communities across the United States. Are you interested in joining one of those networks to provide on-the-ground support? (If so, upon confirmation, your information will be shared with a synagogue leader or a designated representative.)
Yes
No
I need more information
Organizational Affiliation and/or association with an existing local support network (if relevant):
Are you interested in receiving training to become an abortion care support doula?
Yes
No
I need more information
Please briefly summarize your interest in participating in Jofa's S.A.F.E. Plan abortion care support network?
To the extent that you are comfortable sharing, please tell us briefly and confidentially if you have lived experience with any aspect of abortion care, whether yourself or someone close to you, that would be relevant to this project?
