BBC Childbirth Course Registration
Complete this form to register for Birth Boot Camp classes with Sarah Kelchner. A $50 deposit is required to hold your spot; any remaining balance will be due at the beginning of class. Please send payment via PayPal to sarahkelchner@gmail.com or check or money order to Sarah Kelchner 3284 Thompson Road Cazenovia NY 13035
Which series do you plan to attend? (check ALL that apply) *
Required
Name *
Your answer
Birth Partner's name and relationship, if applicable
Your answer
Mailing Address *
Your answer
Phone Number(s) *
Your answer
email(s) *
Your answer
Preferred Method(s) of contact *
Required
Care Provider and Planned Birth Location
Your answer
Estimated Due Date
MM
/
DD
/
YYYY
Do you have any special needs or circumstances you would like me to be aware of?
Your answer
Total number of pregnancies, including this one?
Your answer
Is/was there anything remarkable about your pregnancy/ies that you would like to discuss?
Your answer
How did you hear about Birth Boot Camp? *
Your answer
***Referral Discount*** For every student you refer to this or a concurrent class series, 10% will be deducted from the cost of tuition for you AND your referral. Please list names of referrals here to receive discount. Referral discounts are available up to the date of your last scheduled class.
Your answer
Do you have any additional questions?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service