Matters of Birth Pilot Seminar Application

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Thank you so much for letting me know more about you so that we can determine if this is the right course for you!

Name *

First name

Email *

Phone number

Estimated Due Date *

YYYY

Is this your first birth or... *

First birth

Second Birth

Third Birth

Fourth Birth

More than 4!

Required

Will you attend all seminars as best you can and agree to provide feedback? *

Yes

Can I take photos and videos and use in marketing? *

Yes

Maybe - I'd like to approve first

Required

Do you have special circumstances for your birth? *

Carrying Multiples

Surrogate

VBAC

Scheduled Cesarean

High Risk

None

Other:

If you have any special circumstances, please provide a quick overview below.

Have you taken any childbirth education before, and if so, please list course names.

Would a week night course 7-9PM work for you? *

Yes

Maybe

If there another day/time that will work best for you?

Please let me know why you'd like to attend my "Matters of Birth" Lamaze Childbirth Course

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