Register for Bradley Method® Classes with the Berntsens, AAHCC 2017
Please only use this form if you are taking classes with Nancy & George Berntsen. Otherwise contact your local instructor for registration instructions. This form is secured and the information will not be shared with anyone else. To return to our home page, go to http://naturalbirthprep.com . (The Bradley website: http://bradleybirth.com; our official Bradley webpage: http://bradleybirth.com/nancyberntsen) Options and links to pay your deposit are stated below at the end of the questionairre.
Todays' Date *
Your answer
Which Series you plan to attend: *
General Information
Location of series if known
Your first name *
Your answer
Your Last Name *
Your answer
Your email address *
Your answer
Your phone number(s) *
i.e., H:________, M:__________, W:__________, Spouse (or other...) :____________
Your answer
Your coach/spouse's first name *
Your answer
Coach/Spouse's Last Name
Your answer
Relationship of coach/birth support to you *
Your answer
Your address (Line 1) *
Your answer
Your address (Line 2)
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Baby's Said (estimated) Due Date *
Your answer
Baby's gender *
Use OTHER if multiples or twins to specify
In the event that we need to contact you quickly if a class is cancelled due to bad weather, illness, emergency, etc, what is best secondary way to contact you? *
Examples: phone, alt. phone number, text, email, other: please explain and provide additional info you feel is helpful.
Your answer
Additional Information:
How did you find out about the Bradley Method and about our classes? *
Your answer
Name of Doctor or Midwife or Practice: *
Your answer
Where do you plan to give birth? *
Please provide name of facility and city/state or "Home" or other location as applicable.
Your answer
Years married or together
Your answer
Ages of other children (if applicable)
Your answer
Mom's birth date: *
Your answer
Mom's pre-pregnant height & weight: *
Your answer
Mom's Health Status: *
Your answer
Mom - Smoker? *
Mom's Occupation: *
Your answer
Dad's Date of Birth *
Your answer
Dad's Health Status
Your answer
Dad - Smoker?
Dad's Occupation
Your answer
Who will be the primary coach? Relationship? *
(Typically the baby's father but may be a doula or close relative or friend)
Your answer
Other birth support's name and title or relation if applicable
i.e., sister, friend, doula, mother, etc.
Your answer
Do you plan to take pictures of the birth? *
Your answer
Breastfeeding Questions *
(Check the box(es) for all that apply.
Required
Have you interviewed and/or chosen a pediatrician yet? *
Your answer
What regular physical activities do you engage in regularly? *
Your answer
Childbirth History
# other children you have:
Your answer
# medicated births:
Your answer
# cesarean births:
Your answer
# Bradley Births (if other training, specify)
Your answer
Were there any unusual circumstances with previous births?
Your answer
Have you had any problems or concerns with this pregnancy? *
Do you have any specific questions you'd like addressed privately or at the first class?
Your answer
Series & Payment Information:
Please refer to your email for current rates for your series.
Deposits are as follows: $50 for group, modified group and refresher series, $100 for all private series. Deposits are not refundable. (Balance is due at second class.)

Group & Private Series: We offer all students a loaner binder full of articles and videos. A refundable cash deposit of $40 cash is collected at the first class. This info is also available digitally as pdf files online by request.

What do you hope to get out of this series? *
Name two or three topics you hope to learn more about, regarding pregnancy, birth or breastfeeding.
Your answer
Group Series Tuition Discounts, Credits & Coupons
You may be eligible for tuition reduction. Choose only one discount. Choose "Other" and describe if this is a special discount (such as a coupon, or a certificate of completion of our early pregnancy class.) The discounts are $30 for a standard group series or modfied group series and $50 for a private or semi-private series.
How will you pay for your deposit? *
If you have a signed gift certificate purchased from us and specific to our classes, choose other, include certificate number, and specify amount.
Thank-you for signing up for our classes! We look forward to meeting you and helping you prepare for your upcoming birth! Nancy & George Berntsen
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