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Childbirth Class Registration
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Email
*
Your email
Date of Class I am interested in attending:
MM
/
DD
/
YYYY
Full Name:
*
Your answer
Phone Number:
*
Your answer
Due Date:
*
MM
/
DD
/
YYYY
Are you financially eligible for WIC, or are you receiving any Social Services?
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Yes
No
Other:
Will a spouse, partner, or support person be attending with you?
*
Yes
No
I understand that this class is free of charge and provided by The Mental Health Association and The Birthing Circle. By submitting this application, I commit to attending this class, and if circumstances don't allow me to attend, I will email
thebirthingcircle@gmail.com
as soon as possible so my slot may be opened to another family. (Please type name as Signature).
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Your answer
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