Register For Childbirth Education

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

Will be used for reminder texts

(###)

###

####

Should be an email you actually check, not the junk email

Estimated Due Date

YYYY

Midwife or OB

First Name

Last Name

Birth Location Preference

Home birth, Birth Center or Hospital (give specific location)

Which Childbirth Education Series are you Registering for?

Individual & 1 Support Person

Small Group (3-4 individual/partner)

Digital Only (no consult)

Support Person Name

First Name

Last Name

Support Person Phone

(###)

###

####

Support Person Email

Pregnant Person: There will be required reading for you and your support person, for this series. All reading materials will be available to you in digital format prior to your series beginning. Reading the necessary sections BEFORE attending a session will be crucial to maximizing the benefits of this series and your time.

Please type here to agree that you understand the above statements.

About You

Please share your journey to this pregnancy. Is this your first or fifth? How many live births have you experienced? Please share, at your discretion, about any pregnancies that did not result in a live birth. What are your dreams for this pregnancy and birth?

Support Person: There will be required reading for you and your support person, for this series. All reading materials will be available to you in digital format prior to your series beginning. Reading the necessary sections BEFORE attending a session will be crucial to maximizing the benefits of this series and your time.

Please type here to agree that you understand the above statements.

Support Person - About You

You are free to bring your Mother, Brother, Cousin, Partner, Neighbor, or anyone else you deem safe to support your birth dreams. Tell us a little bit about them and why they will be joining you. Do you have any reservations about having them as a support person for birth? What do you think they may need help with?

Payment: The Fee for each series is $400.00. This fee includes class for one pregnant person and their choice of (1) support person. All sessions of this class will be hands on and interactive, preparatory reading is required. Payment in full must be submitted through Venmo to @Klein-SMVDoula prior to starting the class. In the box below share your Venmo handle:

Anything else?

If you have any concerns, questions, or other information you need to share, please do so here!