The Essentials with a Group Childbirth Class - When Childbirth Class has been Paid

Name (as registered at your birth place)*

First NameLast Name

What do you prefer to be called?

Spouse / Partner/ Support Person's Name (or NA if not applicable)*

First NameLast Name

What do you prefer to be called?

Estimated Due Date

Date

Birth Place (Or undecided if you have not chosen yet)*

Care Provider (Or undecided if you have not chosen yet)*

Mom's Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Mom's Email*

example@example.com

Dad's/Support Person's Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Dad's/Support Person's Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Winter Series - In-person, Tuesdays: February 17, 24, March 3, 10, 17Spring Series - In-person, Tuesdays: May 5, 12, 19, 26, June 2Summer Series - In-person, Mondays: August 10, 17, 24, 31, September 14 (NOTE: No class Sept 7)Fall series - In-person, Tuesdays: October 6, 13, 20, 27, November 3

# pregnancy this is for you

# children you have

Is there anything you would like your doula/childbirth educator to know about your previous pregnancies or births?

Have either of you ever taken childbirth classes before? Please share briefly about your experience(s).

In what ways have you prepared for this birth? What books, movies, etc., have you used for preparation?

Are there any cultural or religious preferences of which your doula/childbirth educator should be aware?

Is there anything you would like for your instructor to know about either of you, anything that might affect or improve your class experience?

YesNo

My typed name below indicates my understanding that the reserved class slot is for two people (expecting person and one support person; you may certainly bring a substitute if your primary support person needs to miss a class). Visitors or additional people are not permitted. I understand also that if the instructor postpones a group class for an emergency, such as a birth, the instructor will offer a makeup date for the class. If I am unable to attend the makeup class, the instructor will work with me to offer a makeup class at our mutual convenience at no additional charge. If I miss a class, private makeup classes are available for an additional fee. There will be no refund for private or group classes that I miss after class has begun.

How did you hear about Debbie's doula service?*

Debbie Hull is currently orienting new backups for her practice. All doulas she works with are completely trained and qualified. Would you be interested in having an additional doula attend your birth? You set parameters about how involved the additional doula will be (only fetching water and towels or more hands-on involvement) and the doula will be prepared to leave at any point per your wishes. If an additional doula is chosen to attend your birth, you will have the option of meeting her via Zoom prior to your birth. No additional doula will attend without your prior approval.*

Yes, I am open to having another doula attend my birth.No, I prefer that only Debbie or her backup attend.

to submit only the retainer at this time.to submit the fee in full at this time.

to submit the fee/retainer via Square invoice.to submit the fee/retainer via PayPal invoice.to mail a check for the fee/retainer.

My typed name below indicates that I understand that I am to CALL, rather than text or email, my doula if I think I am in labor. My typed name also indicates that I have informed my partner and/or support team about this. *

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Mom's Signature*

Dad's/Support Person's Signature*

Please read the Service agreement and sign below to indicate our acceptance of these terms.

Mom's signature indicating acceptance of the terms of the Service Agreement *

Dad/Support person's signature indicating acceptance of the terms of the Service Agreement*

The Essentials Doula Package with a Group Childbirth Class, when the class has already been paid for*

The Essentials Doula Package with a Group Childbirth Class, when the class has already been paid for - In-Full

$2250 less $300 paid for class

$1,950.00 Quantity

The Essentials Doula Package with a Group Childbirth Class, when the class has already been paid for - Retainer only

$2250 less $300 paid for class; Fee remainder due at 37 weeks, home visit, or at birth (whichever comes first)

$800.00 Quantity

Total

$0.00

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