IN Labor/AT Labor Childbirth Class Registration

For which class series do you wish to register? *

Tuesdays, 6:30-9:30 pm: October 15, 22, 29, November 5, 12 Parents Again Refresher course (for parents who took a comprehensive class for a previous pregnancy) Private class (subject to availability and scheduled at our mutual convenience)

Expectant Mother's Name *

First Name Last Name

What name should appear on name tag? (We generally use only first names.)

Best number to which instructor may send text in the event of a class postponement or other emergency *

Area Code Phone Number

Expectant Mother's E-mail *

Partner's Name (or name of other support person who will attend) *

First Name Last Name

What name should appear on name tag? (We generally use only first names.)

How did you find out about this class? *

How did you find out about this class?

Estimated Due Date *

Date Date Picker Icon

Birthplace *

Care Provider *

# Pregnancy *

# of Children *

Do you wish for me to know anything about your previous pregnancies or births?

Have either of you ever taken any other childbirth classes? Please share briefly about your experience(s).

In what ways have you prepared for this birth? What books, movies, etc., have you used for preparation? *

Is there anything else you would like for the instructor to know about either of you, anything that might affect/influence your class experience?

How do you prefer to submit the fee for the class? *

Check on the first day of class (preferred) Cash on the first day of class Square invoice (To be sent to the email address you provided above) PayPal invoice (To be sent to the email address you provided above) Other (please speak to me about special circumstances)

My typed name below indicates my understanding that my slot in class is not reserved until I have received a confirmation email stating that I am registered. *