Antenatal Breastfeeding Classes Registration Form

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Please fill all fields. Keep the Payment reference no sent in SMS by PayUmoney(PAYUMN) handy before filling this form

NAME *

Your Expected Date of Delivery (EDD) *

YYYY

Mobile Number *

Email Address (on which you would like to recieve handouts ) *

Enrolling for *

Day 1

Day 1+ Day 2

PayU Money Payment ID Reference *

This is the 9 digit numeric reference number sent to you by PayUmoney by SMS (from PAYUMN) after you have completed the payment. We need this number to link up your payments.

Consent for participating in online sessions *

Personal information provided by the participants will not be shared to any one by Dr Shacchee Baweja. However, Dr Shacchee Baweja shall not be responsible for any data breach arising out of Google forms or Zoom. The Sessions might be recorded by Dr Shacchee Baweja for internal Quality assessments and can be used for promotion and dissemination of Education but won't be utilised for any commercial purposes. Participants are not allowed to record or share the session's recordings without prior permissions from Dr Shacchee Baweja.

I understand the above clauses.

By checking this box and submitting the form, I submit my consent for participation in online sessions on Zoom

Required

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