Cuidiú Antenatal Ireland (Galway) Booking Form (online March 2021 course)

Cuidiú Antenatal Ireland Small Group Online Course with Tara Durkin, Doula Next Door Galway
www.doulanextdoor.com • www.antenatalireland.ie • 086.232.8229

Saturday March 14th 10am-2pm
Sunday March 21st 10am-2pm

Online via Zoom

Course fee: €160 (pregnant person + partner) includes 1-year's Cuidiú membership

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

Email address *

Name

Age

Address

Phone number

Will your partner or birth companion attend the session with you?

Yes

Maybe

Clear selection

If yes, partner/birth companion's name

Companion's email

Companion's phone number

Are you preparing for your first birth?

Yes

Clear selection

Your baby's estimated birth date

YYYY

Planned place of birth

Type of care (eg., midwives clinic, community midwife, private consultant, etc):

Have you experienced a previous miscarriage or stillbirth?

Have you had any medical conditions or difficulties with this pregnancy?

Any further information, or anything you would like to add?

Is there anything you particularly wish to cover during the course?

Where did you hear about the classes? If Cuidiú website, how did you hear about Cuidiú?

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. Do you consent to this use? *

Yes

Data Protection: 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? *

Yes

Will you be paying your booking deposit by Bank Transfer or PayPal? *

Book by Bank Transfer by sending €50 (using your name as the reference) to Account Name: Tara Durkin, Bank and Branch: PTSB Eyre Square, BIC: IPBSIE2D, IBAN: IE38IPBS99066026023965 (the remaining balance of €110 will be due at the start of the course).

Book by PayPal by sending €50 to antenatalgalway@gmail.com. The balance of €110 is due at the start of the course.

Book by Revolut by sending €50 to 0862328229. The balance of €110 is due at the start of the course.

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