July 18th Online Bradley Method Series
To register for the classes from July 18 to October 10, 2021, please fill out the form below.
Your Due Date
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Mother's Name (First and Last)
Your answer
Mother's Occupation
Your answer
Mother's Phone
Your answer
Mother's Email
Your answer
Coach's Name ( First and Last ) [your partner or the person attending class with you]
Your answer
Coach's Occupation
Your answer
Relationship with Coach (partner, husband, wife, mother, etc.)
Your answer
Coach's Phone
Your answer
Coach's Email
Your answer
Which email do you want me to use for class communication and updates?
Mother's email only
Coach's email only
Both
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Address (Street, Apt. #, City, and Zip please) I am unable to get your Student Workbook from the Academy without this info. Thanks!
Your answer
Birth Attendant's Name (Midwife, OB)
Your answer
Where are you planning to give birth?
Your answer
Besides the medical team, who else will attend the birth?
Your answer
Are you planning to breastfeed your baby?
Your answer
How is your health status?
Your answer
Do you exercise regularly?
Yes
No
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If yes, what do you do?
Your answer
Have you had any problems with this pregnancy?
Your answer
Does anyone in your household smoke?
Your answer
Do you have other children? If yes, please write down their names and ages as well as any special information you would like me to know about their births.
Your answer
What are you are hoping to experience for your birth?
Your answer
What would you like to get out of this class?
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Do you have any special concerns, fears, or circumstances you would like me to know about so that I can be sure to meet your needs during this course? (Please be assured that anything you write is confidential and will not be shared with anyone.)
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How did you find out about this course?
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Thank you for filling out this registration form. I will be in touch with you soon! Warmest, Susan
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