Intro to Charting for Young Women
Registration Form for the Intro to Charting for Young Women Class
For menstruating Young women Ages 9-15 and their Mothers or Female Mentors
Young Woman's Full Name (Client) *
Your answer
Young Woman's Age *
Client's Date of Birth *
MM
/
DD
/
YYYY
Mother/ Female Mentor *
MM
/
DD
/
YYYY
Address *
Your answer
Client Phone number
Your answer
Client Email
Your answer
Phone number of Mother or Female Mentor *
Your answer
Email of Mother or Female Mentor *
Your answer
Date of first menstruation-
MM
/
DD
/
YYYY
How did you hear about the Intro to Charting Class? *
Your answer
Name of Family Doctor/ GYN *
Your answer
Has the young woman ever had a GYN exam? *
If yes to question above, please share the date of exam
MM
/
DD
/
YYYY
We would like to register for the following class *
What interests you most or what is you main reason for registering for this class?
Your answer
Any Questions about the Intro to Charting for Young Women Class?
Your answer
Important Information - Please Read before submitting form
The Intro to Charting for Young Women Class is designed for Young Women who are menstruating (has had at least 1 menstral period) and between the ages of 9-15. Young women over the age of 15 are encouraged to learn the complete Creighton Model FertiltiyCare System.

The Intro to Charting for Young Women class is a two-hour group introductory class. Young Women are encouraged to attend with their mother or Female Mentor. The class will include Introduction to observing, charting, self care, hygiene, communication and an Intro to NaPro Technology for Single women.

Young Woman will receive a paper chart to chart 12 months of cycles. They will learn basic observational and charting skills. This program does not include individualized follow up appointments, however 30 minute chart reviews may be scheduled when needed or requested.

The Intro to charting for Young Women program is not intended to be used for Family Planning and the teaching of days of fertility will be saved for learning in the complete Creighton Model FertiltiyCare System. This system does allow for referral to a NaPro Medical Consultant for access to NaPro Technology if needed. (some additional charting information with Creighton Model FertilityCare chart maybe needed).


Intro to Charting for Young Women includes:

2 hour class to be attended with Mother or other Female Mentor
1 paper chart to chart 1 year of cycles
Self Care and Communication materials
A personal Hygiene product kit (reusable cloth pads)
Light lunch

Fees for Intro to Charting for Young Women Program:

$40.00 Intro to Charting for Young Women group class and all materials
*additional sisters may attend together for $20 each

$30.00 per 30 minute chart review session (when needed/ requested)

* After attending Intro to Charting Class there will be a $25 discount (for mom or daughter) when attending the full Introductory Session of the Creighton Model FertilityCare System.

Registration and payment for the Intro to Charting for Young Women class is required before attendance. You may submit this form and then use the following link to pay via Pay Pal or send a check to:

Orange City FertilityCare Center
127 Albany Ave SE
Orange City, IA 51041
(Please print client's name in memo)

paypal.me/ocfertilitycare/40

You will receive an email to confirm Registration and payment as been received along with location of the class. Please allow 2 business days for processing and then email kbeadner@gmail.com if you don't receive an emailed confirmation.

I have read the above "Important Information" and agree to submitting payment to secure registration for class and materials *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service