IN Labor/AT Labor Childbirth Class Registration

IN Labor/AT Labor Childbirth Class Registration
For which class series do you wish to register? *

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) Summer Series: Tuesdays, 6:30-9:30 pm: July 7, 14, 21, 28, August 4 October Saturday Series, 8 am - 5 pm: October 10 & 17 Fall Series: Mondays, 6:30-9:30 pm: October 12, 19, 26, November 2, 9
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 *
Address - For sending materials for virtual classes *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Husband/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? *
Estimated Due Date *

Month Day Year
Date
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? *
Are there any cultural or religious preferences of which your instructor should be aware?
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. *
Do you wish for your contact information (phone, email) to be included on the class roster to be given to your classmates? *

Yes No
Do you and your husband/partner consent to my using photos I take of your during class for promotion of my classes (Facebook, website, other)? *

Yes No
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