Full Name of Pregnant Parent *

Note: please type first name as you prefer to be called on name tag

Full Name of Attending Partner (if applicable)

Note: please type first name as you prefer to be called on name tag

Relationship to Pregnant Parent *

Does Attending Partner plan to provide labor support to pregnant parent? *

Yes

No

Maybe/not sure yet

Not applicable

Home Address (or town/neighborhood)

Email *

This will be used for post-class homework emails, class contact list for sharing baby announcements, etc.

Attending Partner's Email

This will be used for post-class homework emails, class contact list for sharing baby announcements, etc.

Pregnant Parent's Age

Estimated Date of Delivery *

Baby gender *

Boy

Girl

Unknown

It's a Secret!

Pregnant Parent's Occupation

Partner's Occupation

Name of OB or Midwife *

Where do you plan to give birth? *

Please give specific hospital/birth center name or indicate "home" if home birth

Are you planning to use a labor support doula? *

Yes

No

Undecided

Labor Support Doula's Name

Are you planning to use a postpartum doula? *

Yes

No

Undecided

Postpartum Doula's Name

What are your main wishes for your birth (aside from healthy mom and baby)? Are you hoping to have a natural birth? What does a “natural birth” mean to you? *

Do you feel comfortable with your chosen birth environment and caregivers? *

What books have you been reading (or films have you seen) about pregnancy, labor/birth? Which are your favorites? *

Have you been pregnant before? If so, did you experience any complications? *

Is this your first baby? *

Have you had any prenatal testing such as amniocentesis? Please be specific. *

Do you have any medical condition which you feel may affect your pregnancy, birth or postpartum period? *

How do you plan to feed your baby in early weeks/months? *

Is there anything else I should know about you (including any cultural or religious practices that will be relevant for your birth or early parenting)? *

What topics are most important to you to cover in class? What do you hope to get out of the series? *

Do you have any food allergies or dietary restrictions? *

(for group classes only; private clients please enter NA)

How did you find out about this childbirth education series? *

Childbirth Education Class Registration Form