Mindful Birth NY Childbirth Classes Enrollment Form
So glad you are joining us!

Please send in the $100 deposit payment in one of these methods:
• Venmo (@MaryEsther-Malloy)
• Chase QuickPay / Zelle (maryesthermalloy@gmail.com)
• send deposit via PayPal ($100 + $4 fee)
• arrange a PayPal invoice ($100 + $4 fee)
• mail a check made out to Mindful Birth LLC to: Mary Esther Malloy, 145 James Street, Hastings-on-Hudson, NY 10706

Thank you and I look forward to meeting you soon!

Mary Esther Malloy
maryesthermalloy@gmail.com
347.276.2819

Expectant Mother's Personal Info
Which class series would you like to attend? *
First and Last Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Full Postal Address *
Your answer
Partner's Personal Information
First and Last Name
Your answer
Phone Number
Your answer
Email Address
Your answer
Full Postal Address (if different from above)
Your answer
About the Baby and Birth
Estimated Due Date *
MM
/
DD
/
YYYY
Midwife or Doctor? *
Name of Midwife or Doctor
Your answer
Name of Doula if using doula care
Your answer
Birth Site *
If planning on a birth center or hospital, which one?
Your answer
Is this your first baby? *
If this is not your first baby, what are the ages of your older children?
Your answer
How did you hear about this class? *
Your answer
About You
These are some questions that will help me get to know you. Your responses can be super brief or pages long - however you would like to respond!
How is your pregnancy going?
Your answer
How are you feeling about your upcoming birth?
Your answer
How are you feeling about your doctor/midwife and where you're planning to give birth?
Your answer
Will you be inviting others to join your birth team, such as mother, friend, sister, doula, etc.?
Your answer
How do you see yourself coping well with your labor?
Your answer
How ready do you feel to become a parent (or welcome yet another little one)?
Your answer
Do you have any particular fears or concerns regarding birth or parenting that I should know about?
Your answer
How was your previous birth experience (if applicable)?
Your answer
Do you have any medical challenges I should be aware of?
Your answer
What have you found to be a particularly inspiring resource for birth and/or parenting?
Your answer
To confirm your enrollment, please send a deposit of $100 (or $100+$4 fee for PayPal). The total fee for the class is $475 downtown/$400 Inwood, $395 for special intensive, including the deposit. The balance is due at the first class unless other arrangements are made. The refund policy is as follows: the deposit is non–refundable. If after the first class you need to cancel, the initial deposit will be retained and any balance paid will be refunded, minus a $50 cancellation fee and $35 materials fee, unless the workbook is returned. Subsequent refunds/deductions after the first session will be not be available. Thank you for your understanding. Please let me know in writing if you would NOT like to be included in an email contact list with your classmates, which will be shared during and/or at the end of the class series. Also please let me know in writing if you do NOT approve my use of photographs taken during class for my website, your group's Facebook page, and/or other promotional materials. *
Required
How will you pay the $100 deposit? *
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