Birthing From Within Class Registration Form
All information is confidential. How much and what you share is up to you.
Email address *
Birthing person's name *
Partner's name
Estimated due date *
MM
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DD
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YYYY
Mailing address
Phone(s)
Birthing person's age
Birthing person's occupation
Partner's age
Partner's occupation
Doctor/Midwife
Intended birthplace
First pregnancy?
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Miscarriages?
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Fertility issues/IVF?
Ages of other children
Are you using a doula? If so, whom?
Preferred class series (which start date?)
What do you already know about the Birthing From Within style of childbirth preparation?
Birthing Person: What are you hoping to get out of our time together?
Birthing Person: Do you have any specific topics, questions, or concerns you want covered in class?
Partner: What are you hoping to get out of our time together?
Partner: Do you have any specific topics, questions, or concerns you want covered in class?
Is there anything else either of you want me to be aware of?
How did you find out about this class?
Hold your spot with a $50 non-refundable deposit:
Clear selection
The remainder of the class fee is due on or before the first class and can be paid by cash, check, or PayPal. Check here if you want information about flexible payment arrangements.
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A copy of your responses will be emailed to the address you provided.
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