2020 Enrolment Form - Positive Birth Program
Email *
Please select the month your classes begin *
Type of class *
Mother's First Name *
Mother's Last Name *
Partner's First Name *
Partner's Last Name *
Partner's E-mail Address *
Please indicate if your partner would also like to receive the course e-mails *
Address Line 1 *
Address Line 2
Suburb *
Mother's mobile number *
Father's mobile number
Name and contact number of other birthing assistants (doula/relative etc)
Hospital/Birthing facility *
Care Provider's Name *
Estimated Due Date *
MM
/
DD
/
YYYY
Is this your first, second, third etc baby? *
Is this birth a VBAC or is there any other important information, medical conditions, psychological or psychiatric treatment you need me to be aware of before classes commence? *
Start date (first class) of the course you would like to enrol in. *
MM
/
DD
/
YYYY
How did you hear about Sam's classes? *
Required
In order to secure your position in the program a $165 deposit is payable to the details below:
Samantha Lancaster
306 134
0402601

Full payment is required 1 week prior to the first class. An invoice for the balance will be sent via e-mail following confirmation of enrolment, including deposit payment.
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