Application

Find out if you meet the criteria and conditions to apply

APPLICATION FOR PARTICIPATION

PART 1: Applicant’s Details

Full Name

Father’s Name

Date of Birth

Place of Birth

Address of Residence

Area / Postal Code

ID Card / Passport Number

Language(s) of Communication

Phone Number

E-mail

Family Situation

Are you pregnant or have you recently given birth?

Pregnant

(Month of pregnancy:)

(Expected date of delivery:)
Gave birth in the last 12 months

(Baby’s age: months)

Is this your first pregnancy?

Number of Children

PART 2: Questionnaire

1. We would love to know what brought you here! Please tell us the reason why you are contacting us.

2. How would you like us to support you?
(Please tick (√) one or more options)

Midwife support
Psychology support
Family helper
Career counselling

* MaMa provides pregnant women and mothers who join the program with personal hygiene products and baby essentials.

3. Is there someone (e.g. family, friend) who supports you and is there for you?
(Please tick (√) the appropriate option)

Yes – Please describe the relationship
No
Other – Please describe

4. Financial situation:
(Please tick (√) the appropriate option)

No income
Monthly income up to the minimum wage (830,00 €)
Monthly income above the minimum wage – Please define
Please define whether the income mentioned above is:
- Personal
- Family

5. Professional status:
(Please tick (√) the appropriate option)

Public sector employee
Private sector employee
Freelance
Unemployed
Other (Please specify)

6. Please tick (√) the highest educational level you have completed:

Primary school
Secondary – High school
University
Other (Please specify)

7. Are you experiencing any complications in your pregnancy?
(Please tick (√) the appropriate option)

Yes – Please describe
No

8. Do you have any history of psychiatric diagnosis?
(Please tick (√) the appropriate option)

Yes – Please describe your diagnosis
No

9. Are you currently taking any medication for a health condition?
(Please tick (√) the appropriate option)

Yes – Please describe
No

10. How did you hear about us?
(Please tick (√) the appropriate option)

Social media (Facebook, Instagram, etc.)
Referral from a professional (e.g. midwife, social worker)
Friend
Other (Please specify)

I UNDERSTAND and ACKNOWLEDGE that MAZI SOU MAMA provides consulting services and does not undertake nor perform medical procedures or medical monitoring.
I declare that I wish to attend the scheduled meetings, which will be mutually arranged with MAZI SOU MAMA’s professionals. In case I am unable to attend these meetings, I will inform MAZI SOU MAMA in a timely manner.
I wish for midwifery services to be provided at my residence, in accordance with an agreement with MAZI SOU MAMA.
I ACCEPT and AGREE that MAZI SOU MAMA team bears no responsibility for the quality of any product I may receive as a donation from them.
I do not use narcotic substances.
To date, I have not been convicted of any criminal offense.
I AGREE to provide as many of the following documents I have in my possession or can obtain, and I AGREE to be collected and filed by MAZI SOU MAMA:

▪ Copy of my ID or passport.

▪ A document certifying my permanent residence or stay (e.g. lease agreement, certificate of residence, utility bill).

▪ Tax certification or salary statement.

▪ Certificate of family status.

▪ Residence permit in Greece (if required by Greek legislation).

▪ Psychiatric certification, in case of psychiatric diagnosis.

Date

Signature

*Note: This application does not constitute a consent form within the meaning of Article 6(1)(a) of the GDPR, but rather an act of participation in a social support program, where data processing is carried out on the basis of the aforementioned legal grounds.

Application

APPLICATION FOR PARTICIPATION

PART 1: Applicant’s Details

PART 2: Questionnaire

I want to download the application form and send it by post or electronically.