Group Class Registration Sheet

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Congratulations on your pregnancy! I'm looking forward to meeting you and am excited to help you prepare to welcome a new life into your family. Please select classes that fall in your third trimester of pregnancy.

If a class is listed as *VIRTUAL* it will meet over zoom and you'll be mailed your materials ahead of time.

If a class is marked *FULL*, you will be added to the class wait list and notified as soon as possible should a space become available.

Olympia Obstetrics & Gynecology - 615 Lilly Rd NE #200, Olympia, WA, 98506. *Please note that per WA state DOH, masks remain required in healthcare settings regardless of vaccination status.*

True Self Wellness - 2727 Westmoor Ct SW, Olympia, WA 98502

Your name & pronouns: *

Partner or Support Person's name, pronouns, & relationship to birthing parent:

Your prenatal provider:

Your Planned birthing location:

Your estimated due date: *

YYYY

Have you given birth previously?

Yes, I have an older child (or children).

No, this is my first child.

Email address: *

You'll receive a registration confirmation at this email as well as all relevant class emails. Your email address is never shared or used for marketing.

Partner or support person's email address:

Please include if you'd like them to also receive class emails.

Phone number: *

Your address:

Doula:

Please complete the following to register for a 4 week series OR a one day Saturday childbirth education class

(No 4 week sessions are currently scheduled)

Please select to register for a one day Saturday class:

Cost: $160 for a one day class on Saturday from 9am - 4pm. Class is led by a certified childbirth educator.

What is important for you to learn from this class?

Do you have any special circumstances you'd like me to be aware of? (multiples, high risk pregnancy...)

Please complete the following to register for Lactation & Newborn Care

Please select a class:

Cost: $60 for 1 evening class. In person classes meet Tuesday or Thursday from 6 - 8:50pm at Olympia Obstetrics. (This class is NOT covered by Provider One insurance.)

What is important for you to learn about breastfeeding & newborn care?

How many will attend the lactation & newborn care class?

Due to social distancing classes, in person classes are kept small, please let me know if you'll be attending with a support person or on your own so I can arrange proper seating. (Your support person is welcome and encouraged to attend!)

Payment - *Your registration is not complete and your spot in the class is not guaranteed until payment has been submitted or payment arrangements have been agreed upon.*

If payment is an issue, please let me know in the comments section, payment plans, sliding scales, or scholarships may be available on a case by case scenario. If paying by cash you will need to drop off the cash payment in advance of the classes.

Your payment method: *

Provider One Billing Information

Example of Provider One info: Sally Jones, 4/16/1985, 202123456WA.

**Note that Provider One covers childbirth education but DOES NOT COVER lactation classes. If you've registered for both please follow the prompts after completing this form to submit a payment for the lactation class only.**

**Clinicians / nurses registering on behalf of a client / patient: THE STUDENT MUST COMMUNICATE AND RESPOND TO EMAILS THEMSELVES TO CONFIRM THEIR ATTENDANCE. Due to the high number of provider one no shows I will not accept students without communication directly with me. Please advise your client / patient to monitor their emails and respond or their spot will be released to another family hoping to attend.**

Cancellation / No Show / Refund Policy *

CANCELLATION / NO SHOW / REFUND POLICY --- If you've registered and paid for classes and are unable to attend, the instructor will refund your registration less a $10 processing fee. Cancellations must be received at least one week prior to the first day of class in order to be eligible for a refund. Please allow up to two weeks for your refund to be processed. If you cancel less than one week prior to the first day of class you are not eligible for a refund. If you "no-show" for a class you've registered for and have not given prior notice to the instructor you will be responsible for the full class fee. In the rare case of inclement weather, or instructor emergency or illness when a substitute is not available, classes may be cancelled. Every effort will be made to provide as much notice as possible and to schedule a make up class as soon as possible. In cases where a make up class is not possible, a partial or full refund may be available.

I agree

Any other comments or special circumstances you'd like to share:

Finally, how did you hear about Foveo Birth & Baby classes? *

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