Enter Your Student Data
Enter the information taken from the student registration form.
Student Number *
Remove the last 2 digits of your Teacher Number and add the 3 digit student number. (The last digits of you first student will 001, then 002, etc.)
Your answer
Series Number *
Your first class will be series 1, second series 2, etc.
Your answer
Date Classes Began *
Enter Date of First Class
Your answer
Mother’s First name *
Your answer
Mother’s Last Name *
Your answer
Father’s First Name *
Your answer
Father’s Last Name *
Your answer
Mother’s Email Address *
Your answer
Father’s Email Address *
Your answer
Mother’s Occupation *
Your answer
Mother’s Phone Number *
Your answer
Father’s Occupation *
Your answer
Father’s Phone Number *
Your answer
Mother’s Nationality *
Your answer
Mother’s Religion *
Father’s Nationality *
Your answer
Father’s Religion *
Prior Birth Stats [Unmedicated] *
0
1
2
3
4+
Unmedicated
Medicated Vaginal
Cesarean
Planned Birthplace *
Estimated Due Date *
Your answer
Plan to Breastfeed? *
How did she hear about AMANI Birth? *
Your answer
What are concerns about her upcoming birth? *
Your answer
Does she plan to have anyone attend her birth besides her medical team? *
Check all that apply.
Required
Has she read the AMANI Birth book? *
Is she interested in becoming an AMANI Birth Teacher or Doula *
If yes, you may like to send an email to referral@amanibirth.com with her details for follow up.
How much did you charge for your classes? *
Include the Currency (USD, SAR, EGP, etc)
Your answer
In what language are you teaching this class? *
Your answer
Did you provide the mother an original AMANI Birth Student Workbook? *
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