Childbirth Class Registration Form

1-Week Childbirth Class Form

By submitting this form, I/we understand that the cost of a 2 to 2.5 hour series is $62.50 and includes a comfort measures booklet/breastfeeding booklet, and access to my lending library. Enclosed is my/our nonrefundable payment of $62.50. I/we understand that the tuition is non-refundable. However, I/we understand that in the event of preterm birth or early term birth, Jill Childs will refund the portion of the course left unfinished.
Mother or Birthing Person’s Name

First NameLast Name
Phone

Area CodePhone Number
E-mail
Name of person attending class with you: (optional)

First NameLast Name
The person who will attend class with me is my blanks.
Emergency Phone

Area CodePhone Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Estimated Due Date

MonthDayYear
Birth Place
Provider
# Pregnancy
# of Children
Mother or Birthing Person
In what ways have you prepared for childbirth during this pregnancy? (Books, Movies, Websites, Classes)
What areas of pregnancy, childbirth and postpartum do you hope to learn about in class?
What are your plans for coping and comfort during labor and birth?
How do you see your partner's role during labor and birth?
How has your pregnancy been so far?
Do you exercise regularly?

YesNoSometimes
How would you describe your diet?
Do you plan to breastfeed?

YesNoMaybe
Do you have a history of surviving sexual abuse? Though this is a sensitive topic and can difficult to disclose, knowing of your history will help me to care for you well by using a trauma-informed approach.
Any other information or concerns?
Father or Partner
What areas of pregnancy, childbirth and postpartum do you hope to learn about in class?
How do you see your role during labor and birth?
Would you like her to breastfeed?

YesNo
Any other information or concerns?

My Products

Class Deposit$50.00

Remaining Balance $12.50

Quantity

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

1-Week Childbirth Class Form

Mother or Birthing Person

Father or Partner