Birth Boot Camp Student Registration
Welcome to Step 1 of the registration process! This questionnaire will help me get to know you a little better, and give me the information I need to keep in contact with you throughout our time together. Not all questions will apply to you, but please fill it out as thoroughly as you are comfortable doing. The more I know about you, the better I will be able get you the information you need for an AMAZING birth!
*Completion of this form DOES NOT guarantee you a spot in class. You must also complete Step 2 by paying your deposit to hold your spot.*
Email address *
Contact Information
Pregnant Person's Name *
Your answer
Partner's Name (if applicable)
Your answer
Partner's Email Address
Your answer
Address
Your answer
Phone Number *
Your answer
This Pregnancy
Estimate Due Date *
MM
/
DD
/
YYYY
Class series you wish to register for: *
If you have questions about what class is best for you, please email me at melissa@swellbirth.com
Birthing Person's Age
Your answer
Intended Place of Birth
Name of hospital, birth center, home, or undecided.
Your answer
Care Provider's Name
If you currently have one.
Your answer
Care Provider's Practice
Your answer
Past Pregnancies and Family Information
Number of children
Your answer
Number of Medicated Births
Your answer
Number of Unmedicated Births
Your answer
Number of Cesarean Births
Your answer
Number of VBAC Births
Your answer
More about you...
How did you hear about SWELL Birth?
Your answer
How did you hear about Birth Boot Camp?
Your answer
How do you feel about taking childbirth classes?
Your answer
How does your partner feel about childbirth classes?
Your answer
What are you (and your partner) looking to gain from this class experience?
Your answer
Is there anything else you'd like to add?
Your answer
Email to send invoice *
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google.