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 non-standard prenatal testing? 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? *

Photography Release: Birth Matters NYC reserves the right to take photographic images of attendees during class for use in future promotional materials. By registering for class, you agree to allow use of the images for such purposes. *

I have read and understand

Childbirth Education Class Registration Form