refresher class registration form

refresher class registration form

Please choose which class you are registering for: * Private class, time, date, location TBA $250

Mom's Name: *

Partner's Name:

Partner's Relationship to Mom:

Estimated Due Date: *

Address: *

Phone Number: *

Alternate Phone Number:

Mom's Email: *

Partners's Email: *

OB/Midwife's Name: *

Place Planned for Delivery: *

Who is your doula if you are working with a doula?

How did you hear about the class? *

Names and ages of your children: *

Are you planning a VBAC (Vaginal Birth after Cesarean) *

Yes

No

What were your main take aways from your previous birth experience(s)? *

Describe any medical conditions we should be aware of:

What is mom's greatest concern with pregnancy, labor, birth or postpartum? *

What is partner's greatest concern with pregnancy, labor, birth or postpartum? *

What do you hope to gain from this class? *

I have read and agree to the Terms & Conditions. *

I agree

Review the Terms & Conditions here.
You will not be registered for your class until you have paid.
Please pay via PayPal below or if you would prefer to mail in a check, please contact info@twodoulasbirth.com to receive further instructions.

Class Registration Options

Public class $150.00 USD Private class $250.00 USD