Childbirth Class Registration Form |
Your Name: __________________________________________
Address: _____________________________________________
Phone: ______________________________________________
Email: ______________________________________________
Occupation: __________________________________________
Partner’s Name, if applicable: ____________________________
Phone: ______________________________________________
Occupation: __________________________________________
What is your estimated due date? _________________________
Do you have other children? _____________________________
What are their ages? ____________________________________
Where were they born? _________________________________
Any complications with past pregnancies or labors? For example, miscarriages, prematurity,
episiotomy, anesthesia reactions, etc.
Are you having any difficulties with this pregnancy?
With whom are you receiving prenatal care?
Where will you give birth?
Besides your partner, do you plan to have anyone else to assist you at the birth?
(Birth doula, mother, friend, etc.)
Do you intend to breastfeed?
How did you hear about the classes?
Do you have both a DVD and VCR (for private classes or hosting couples of group classes)? Yes No
Anything else it would be helpful for me to know?
Class Dates:_____________Times:_ _________Tuition Amount: ______________Deposit Enclosed:_____________
I require half of the class tuition to be included with your registration to reserve your class dates;
a check for your deposit may be included with your mailed-in registration or you may pay using my Paypal address.
(Please notate the class dates with your payment if paying by Paypal AND whether you will be sending your registration by mail or email.
Thank you!)
Your dates and spots are NOT reserved until the deposit is received.
The second half should be paid at the first class.
Refunds of your initial deposit will be given if you should need to cancel prior to one month before first class;
this will allow me time to refill these spots with other clients. After this date, no refunds for cancellations will be issued.
Please send completed registration form and your deposit to:
Kristen Gibson
359 Dawnridge Lane
Troutville, VA 24175