Birth Boot Camp Registration
Refresher Course
Which class are you registering for? *
Mom's Full Name *
Your answer
Partner's Full Name *
Your answer
Mom's e-mail address *
Your answer
Mailing Address (Address, City, Zip)
Your answer
Mom's Phone Number *
Your answer
Partner's Phone Number *
Your answer
Estimated Due Date *
MM
/
DD
/
YYYY
Name of Doctor or Midwife *
Your answer
Birth Place (Hospital, Birth Center, Home) *
Your answer
Please briefly tell me about your birth experience(s). *
Your answer
What do you hope to achieve from attending this class? *
Your answer
Do you have any health concerns I should be aware of?
Your answer
Do you plan to have a doula, family, or friends at your birth?
Your answer
Is there anything else you would like to tell me about yourself or your pregnancy?
This information will not be shared.
Your answer
How did you hear about this class?
Your answer
Payment Options *
Your $25 deposit holds your spot in class. The remaining $50 is due at class (cash or check).
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