Cuidiú Antenatal Ireland (Galway) Booking Form (November 2019 course)
Cuidiú Antenatal Ireland Small Group 2-Day Course with Tara Durkin, Doula Next Door Galway
www.doulanextdoor.comwww.antenatalireland.ie • 086.232.8229

November 10th & 17th 2019
10am - 2:30pm
The Resting Tree, Bohermore, Galway city

Course fee: €160 (includes 1-year's Cuidiú membership)

To register for this course, please complete this form and pay €50 deposit to hold your place.

Name
Your answer
Age
Your answer
Address
Your answer
Phone number
Your answer
Email
Your answer
Will your partner or birth companion attend the session with you?
If yes, partner/birth companion's name
Your answer
Companion's email
Your answer
Companion's phone number
Your answer
Is this your first pregnancy?
Your baby's estimated birth date
MM
/
DD
/
YYYY
Planned place of birth
Your answer
Type of care (eg., midwives clinic, community midwife, private consultant, etc):
Your answer
Have you experienced a previous miscarriage or stillbirth?
Your answer
Have you had any medical conditions or difficulties with this pregnancy?
Your answer
Any further information, or anything you would like to add?
Your answer
Is there anything you particularly wish to cover during the course?
Your answer
Where did you hear about the classes? If Cuidiú website, how did you hear about Cuidiú?
Your answer
Data Protection: Your email address will only be used to send you links to articles and handouts as part of the course material, and to arrange Cuidiú meet-ups such as a postnatal reunion for those who took classes with you or around the same time. Your information will not be shared without your consent. There is an offer of one-year’s Cuidiú membership, free with the antenatal course fee. Do you give permission for your contact details (name, email, mailing address and phone number) to be sent to the Cuidiú national membership secretary to avail of membership?
Will you be paying your booking deposit by Bank Transfer or PayPal?
Any other comments
Your answer
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