Thoughtful Birthing Registration

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THOUGHTFUL BIRTHING

Please complete the online registration form. Once your registration information has been received, you will be sent an invoice.
Payment can be made by cash, check, or Paypal.
Unless a payment plan has been approved, payment must be received, in full, 7 days prior to the start of class.
After registration and payment have been received, you will be contacted with more information about your THOUGHTFUL BIRTHING class.

* Indicates required field

Birthing Person *

First

Last

Birthing Person's Phone # *

Birthing Person's Email *

Partner *

First

Last

Partner's Phone # *

Partner's Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Due Date *

Doctor or Midwife's Name *

Hospital/Birth Center/Home *

Ages of Any Other Children *

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

Yes No

If yes, where? *

Birthing Person

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 the birthing person 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 the birthing person's 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? *

THOUGHTFUL BIRTHING OPTIONS *

Summer 2018 Series Fall 2018 Series

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