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 *
Partner's Name (if applicable)
Partner's Email Address
Address
Phone Number *
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
Intended Place of Birth
Name of hospital, birth center, home, or undecided.
Care Provider's Name
If you currently have one.
Care Provider's Practice
Past Pregnancies and Family Information
Number of children
Number of Medicated Births
Number of Unmedicated Births
Number of Cesarean Births
Number of VBAC Births
More about you...
How did you hear about SWELL Birth?
How did you hear about Birth Boot Camp?
How do you feel about taking childbirth classes?
How does your partner feel about childbirth classes?
What are you (and your partner) looking to gain from this class experience?
Is there anything else you'd like to add?
Email to send invoice *
Submit
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