Prepared Childbirth-private

831.521.1045

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YOUR BIRTH EXPERIENCE

Please complete the online registration form, indicating your payment method. Once your registration information has been received, you will be sent an invoice.
Payment can be made by cash, check, or Paypal. Payment must be received within 5 days of registration.
After registration and payment have been received, you will be contacted to set up your private Prepared Childbirth series.

* Indicates required field

Mom *

First

Last

Mom's Phone Number *

Mom's Email *

Partner *

First

Last

Partner's Phone Number *

Partner's Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Due Date *

Doctor or Midwife's Name *

Hospital/Birth Center *

Ages of Any Other Children *

If you have other children, did you take childbirth classes during a previous pregnancy? *

Yes No

If yes, where? *

Mom

Age *

Occupation *

Educational Background *

Do you exercise regularly? *

Yes No

If yes, what do you do? *

How would you rate your diet? *

How would you rate your ability to cope with stress? *

Would you like to breastfeed? *

Yes No

What areas of pregnancy and/or childbirth do you especially hope to learn about in class? *

What are your plans regarding the use of pain relief medication for labor and birth? *

Any special information that you feel the childbirth educator should be aware of? *

Partner

Age *

Occupation *

Educational Background *

Do you exercise regularly? *

Yes No

If yes, what do you do? *

How would you rate your diet? *

How would you rate your ability to cope with stress? *

Would you like for her to breastfeed? *

Yes No

What areas of pregnancy and/or childbirth do you especially hope to learn about in class? *

What is your understanding of her plans regarding the use of pain relief medication for labor and birth? *

Any special information that you feel the childbirth educator should be aware of? *

Payment Method *

Cash Check Paypal

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