Workshop Registration Form
Pop some (um...non-alcoholic?) champagne! You're on your way to being a more calm, confident, and in control parent!
Name
Prefix
First Name
Middle Name
Last Name
Suffix
E-mail
*
example@example.com
Contact Number
*
-
Area Code
Phone Number
Is this number "textable?"
Yes
No
Gender
Male
Female
Prefer not to say
Other (please feel free to specify in notes at bottom)
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
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1987
1986
1985
1984
1983
1982
1981
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1979
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1975
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1971
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1969
1968
1967
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1963
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1961
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1958
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1955
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1950
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1948
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1945
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1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Birth Partner/Support Person's Name (if applicable)
Prefix
First Name
Middle Name
Last Name
Suffix
Contact Number
*
-
Area Code
Phone Number
Is this number "textable?"
Yes
No
Intended Place of Birth
Is this your first birth?
Estimated Due Date
Workshop Format
Online Workshop
In-Person Workshop
VBAC
Which workshop date are you registering for?
Let's set up a date/time frame that works for me!
July 26-27
August 16-17
Have you used GentleBirth materials in the past? Check all that apply:
No, this is the start to my more positive birth!
I've taken a GentleBirth workshop
Read "GentleBirth"
Read "Mindful Pregnancy"
Used the GentleBirth app
Other
Why have you chosen GentleBirth to prepare for your birth?
Have you started your daily practice using the GentleBirth App?
Yes
No, but I will be soon!
How did you hear about GentleBirth?
Do you have any special dietary requirements? (applicable for some in-person workshops)
Are there any special circumstances you'd like your instructor(s) to know about in confidence (i.e. medical condition, mental health concerns, previous birth or sexual trauma, etc)?
Anything else you'd like your instructor(s) to know before we dive into the workshop?
Payment
*
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USD
Please pay $250 for in-person workshop
Credit Card
Submit Application
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