Private Childbirth Class Registration Form

Mother's Name

First NameLast Name

Mother's Phone

Area CodePhone Number

Mother's E-mail

Partner's Name

First NameLast Name

Partner's Phone

Area CodePhone Number

Partner's Email

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Estimated Due Date

MonthDayYear

Birth Place

Provider

# Pregnancy

# of Children

Have you taken childbirth classes in the past?

In what ways have you prepared for childbirth during this pregnancy? (Books, Movies, Websites, Classes)

What areas of pregnancy, childbirth and postpartum do you hope to learn about in class?

What are your plans for coping and comfort during labor and birth?

How do you see your partner's role during labor and birth?

How has your pregnancy been so far?

Do you exercise regularly?

How would you describe your diet?

Do you plan to breastfeed?

Any other information of concerns?

Have you taken any childbirth classes in the past?

In what ways have you prepared for childbirth during this pregnancy? (Books, Movies, Websites, Classes)

What areas of pregnancy, childbirth and postpartum do you hope to learn about in class?

What is your understanding of her wishes for coping and comfort during labor and birth?

How do you see your role during labor and birth?

Do you exercise regularly?

How would you describe your diet?

Would you like her to breastfeed?

Any other information or concerns?

Private Childbirth Class Form