Cuidiú Antenatal Ireland (Galway) Booking Form (online January 2021 course)
Cuidiú Antenatal Ireland Small Group Online Course with Tara Durkin, Doula Next Door Galway
www.doulanextdoor.comwww.antenatalireland.ie • 086.232.8229

Saturday January 23rd 10am-2pm
Sunday January 24th 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
Email
Will your partner or birth companion attend the session with you?
Clear selection
If yes, partner/birth companion's name
Companion's email
Companion's phone number
Are you preparing for your first birth?
Clear selection
Your baby's estimated birth date
MM
/
DD
/
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? *
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? *
Will you be paying your booking deposit by Bank Transfer or PayPal? *
Any other comments
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