Take Charge of Birth Program Application

Questions? Contact me at Carly@EmpoweringMomsBirth.ca
Full Name *
Email *
Are you applying for the Full Year Membership or do you prefer the monthly option? *
Required
Have you attended one of our Empowered Birth Workshops? *
Are you currently pregnant, and if yes, how many weeks? (You do not have to be currently pregnant to be considered for the program) *
Is this your first baby? *
If currently pregnant, who is your care provider?
Clear selection
Do you have a doula?
Clear selection
If you could design your birth any way you want, how would it go?
What other preparations have you made for your pregnancy or birth plans? *
Do you intend to do everything possible to attend the classes live? *
What's your biggest reason for joining this program? *
What interests you about this program the most and why? *
Why do you feel you will be an asset to our community? *
What experiences, insights, or knowledge can you bring to the community? *
How do you plan to empower the other moms in our community? *
Is there anything else you would like me to know about you? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy