Name
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First Name
Last Name
Email
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Phone
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(###)
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####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is your estimated due date?
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Do you have any other children? If so, please list their ages.
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Have you previously had a vaginal birth, cesarean birth or vaginal birth after a cesarean? Please list all that apply.
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Are there any details about your pregnancy or overall health that we should know about?
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Who is your OBGYN?
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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.)
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Are you currently employed?
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If you are employed, what is your monthly income?
What are your total monthly expenses?
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Please briefly explain how this Community Birthing class will be of benefit to you at this time:
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Upcoming class dates are listed below. Please select your preferred session:
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Upcoming class dates are listed below. Please select your preferred session:
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The value of this programme is $300. 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.)
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If you selected "Scale 4 - Custom", please confirm the amount you agree to pay for this programme.
How did you hear about the ITAV Community Birthing Class:
These classes are funded by the It Takes A Village Foundation (ITAV). ITAV provides additional support to pregnant and post-partum women. As the donor, ITAV will review all registration forms. Do you consent to being contacted by ITAV for follow up or additional services?
By completing this registration, for the Community Birthing Classes , you acknowledge that these classes are for educational and informational purposes only. They do not constitute medical advice. The information provided may or may not apply to your personal circumstances and pregnancy. You agree to use this information alongside your values, preferences, and clinical circumstances to make informed choices about your birth. These classes also offer an opportunity to engage in meaningful conversations with your healthcare providers. By participating in the classes, you release the Women's Resource Centre, the facilitator and It Takes a Village Foundation from any responsibility for adverse outcomes resulting from your sole reliance on the information provided or any decisions you make regarding your healthcare.
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Age
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Race
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Black
White
Asian
Mixed
Other
Nationality
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Marital Status
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Check all that apply
Employment Status
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Number of dependant children
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Income
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Level of education
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Primary School
Secondary School/GED
Associates
Undergraduate
Postgraduate
Doctorate
Referred by
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If response is 'Other' to the question above - Please specify
