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EMP Scholarship Nomination Form

We believe every woman deserves access to the best in perinatal health.
If you know a mother who could benefit from the gift of an EMP Membership, please nominate her below.

2024 Scholarship Nominations close on 5 April 2024.

Click the button below to start.

Start

Question 1 of 5

Who are you nominating for an EMP Scholarship and their contact details

(Please note that any contact details will only be used to contact successful recipients and for no other purposes).

Question 2 of 5

Please share why you are nominating this person and why you think they would benefit from an EMP Scholarship. Please note that your response will remain confidential unless you and your nominee consent to your answer being shared).

Question 3 of 5

We believe in the power of stories. We want to inspire others to take small steps to support their friends and loved ones. If your nominee is successful,  would you be open to sharing parts of this submission (subject to your nominee providing their consent)?

A

Yes

B

No

Question 4 of 5

The EMP Scholarships offered to women experiencing hardship in one or more of the following areas. Please indicate if your nominee would meet any of the following criteria (your answers will remain confidential).

(Select all that apply)
A

Financial Hardship and / or Loss of Employment

B

Previous Birth Trauma or Birth Related Injury

C

Prior Pregnancy Loss or Infant Loss

D

Prior or ongoing Mental Health Issues

E

Loss of Emotional Support / Grief

F

Domestic Violence

G

Other (please share details in final question).

H

Prefer Not to Say

Question 5 of 5

Is there anything else you would like to share?

Confirm and Submit