Welcome to Your Childbirth Education Series!
Childbirth Education Series Information Form
Congratulations on your pregnancy! Your love and dedication to your baby is already evident as you strive for a great pregnancy and labor. I look forward to working with you!

Please note that we will be sitting on the floor at times throughout the class. Please bring a yoga mat or blanket and pillows with you and dress comfortably!

Feel free to contact me with any questions or concerns you may have:
Becca: (518) 524-3515

If you could answer a few questions for me prior to the first class, I would appreciate it!
Mother's First and Last Name *
Your answer
Mother's Cell Phone Number *
Your answer
Mother's Email Address *
Your answer
When is your estimated guess date? *
MM
/
DD
/
YYYY
Partner's First and Last Name *
(Who will be present at the birth and attending class with mom)?
Your answer
Partner's Cell Phone Number *
Your answer
Partner's Email Address *
Your answer
Mailing Address *
Your answer
Who is your care provider for this pregnancy? *
Your answer
Where is your planned place of birth? *
(If at a hospital, please tell me which one)
Your answer
Do you plan to have any other labor support present at birth? *
If yes, who will be attending birth other than your partner?
Your answer
Do you have any other children? *
If you have other children, please list their ages below: *
Your answer
List any special concerns or information you would like me to know prior to starting class: *
Your answer
Are you cleared by your provider for physical activity?
Your answer
How did you hear about this series? *
Your answer
Which series are you signing up for? *
See you there!
Your answer
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