Birth-Empowered Bradley® Childbirth Class Registration
 Virtual Interactive Bradley® Childbirth Series
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Email *
Partner's e-mail if she or he wishes to receive communications about the class. Otherwise, I will just use the one on the beginning of this form.
Due Date *
Mother's Name (First and Last) *
Mother's Occupation
Preferred phone number(s) *
Coach's Name (First and Last).  This is your partner or the person attending class with you. *
Coach's occupation
Address for mail (You will receive snail mail from me when the class ends) Please remember your apartment #, city, and zip code. *
Year of mother's birth
Year of coach's birth
With whom are you receiving prenatal care? *
Where do you plan to give birth *
Required
If hospital or freestanding birth center, list name
Besides the medical team, who else will attend the birth?
Please check all the ways you learned about these classes? *
Required
Do you have any specific goals for the upcoming labor/birth/postpartum?
What areas do you feel you need the most information?
What are your coach's concerns about the pregnancy/birth/postpartum?
Any other Children?
If so, what are their names and ages?
Anything else that would be helpful for us to know?
I understand that Karen Wallace and Jeff Dean are affiliated Bradley® instructors and are trained to teach couples about natural childbirth, they are not practicing medicine and that the refund policy is the classes are nonrefundable. If you need to reschedule you can switch to another class if space is available. *
Day of week *
Date Starting *
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Thank you for filling out this form. I will be in touch with you soon!  
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