Your Birth Experience-Winter 2016

831.521.1045

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YOUR BIRTH EXPERIENCE (WINTER 2016)-REGISTRATION

February 6 9:00am to 2:00pm $100

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 (credit/debit card). Payment must be received within 7 days of registration.
After registration and payment have been received, you will be contacted with details about your Your Birth Experience class.

* 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? *

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? *

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? *

Submit

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