Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is your estimated due date?
*
Do you have any other children? If so, please list their ages.
*
Have you previously had a vaginal birth, cesarean birth or vaginal birth after a cesarean? Please list all that apply.
*
Are there any details about your pregnancy or overall health that we should know about?
*
Who is your OBGYN?
*
Will you be attending the classes with a birthing partner? (Note: A birthing partner is the person who will support you during labour and birth. It could be your partner, co-parent, family member or friend.)
*
Are you currently employed?
*
If you are employed, what is your monthly income?
What are your total monthly expenses?
*
Please briefly explain how this Community Birthing class will be of benefit to you at this time:
*
Upcoming class dates are listed below. Please select your preferred session:
*
The value of this programme is $350. However, to make it accessibale to all, the class fee is offered on a sliding scale. Please select the scale best suited for you. (Note: Amount is for the entire 3 session programme.)
*
If you selected "Scale 4 - Custom", please confirm the amount you agree to pay for this programme.
Age
*
Race
*
Black
White
Asian
Mixed
Other
Nationality
*
Marital Status
*
Check all that apply
Number of dependant children
*
Income
*
Level of education
*
Primary School
Secondary School/GED
Associates
Undergraduate
Postgraduate
Doctorate
Referred by
*
If response is 'Other' to the question above - Please specify
