Childbirth and Newborn Care Class Registration
Please complete this form to register for an upcoming childbirth and newborn care series.
Self-paced breastfeeding course also included for families choosing to breastfeed.
Registration for 2021 Class Series *
Your Estimated Due Date *
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About You
Birthing mother's name
Father or Partner name
Who is your care provider? Where will you give birth?
Best email address for class correspondance *
Phone number *
Background Information
What number pregnancy is this for you? Have you previously given birth? If yes, how old are your children?
What are you looking forward to in birth?
Do you have any fears/concerns about birth?
Partner/Spouse attending birth?
Any physical problems with this pregnancy?
Have you experienced any pregnancy losses or fertility challenges? If so, how is this reflected in you during this current pregnancy?
What have you read on pregnancy and birth?
Why did you choose this particular course?
About Your Birth
What is your vision for this birth?
How do you feel about medical procedures/interventions in birth?
How do you feel about natural (unmedicated/drug-free) childbirth?
Are there any cultural or religious considerations that will be reflected in your birth?
If safety were not a concern, what is your dream location for giving birth?
How did you hear about this class?
Other Comments?
Thank you!
I look forward to seeing you in class!
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