LVHN Raising A Family - Prenatal Classes and Hospital Tours

Birthing Mother Name:*

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Date of Birth:*

Phone Number:*

Email:*

Confirmation EmailPlease enter email address again.

Are you currently pregnant?*

YesNo

Congratulations! How many weeks pregnant are you?

Less than 20 weeks20 to 26 weeks27 to 36 weeks37 to 40 weeks

Reminder: Please be sure your class(es) and tour are scheduled between your 28th to 36th week of pregnancy.

Estimated Due Date:*

Provider Name:*

MD, Midwife, etc.

If your Provider is not listed, please type their name below.

Are you in need of an LVHN provider? If so, please click here to view our list of Obstetrics and Gynecology providers.

I understand that cancellations/reschedule requests for in-person classes received less than 48 hours prior to class start time will not be eligible for a refund.

Yes, I understand.

What to Expect and What to Pack:

Were you able to schedule and/or will attend all classes prior to your estimated due date? Exception: You may schedule/attend the Breastfeeding and Returning to Work class after you have given birth.*

YesNo

If you were unable to schedule and/or attend all classes prior to your estimated due date, please contact ParentEd@lvhn.org for assistance. Thank you!

Which Practice do you regularly visit?*

If your Practice is not listed, please type the office name below.

Hospital Campus where you are expecting to birth:*

If Other, where are you expecting to birth?

Will your support partner attend this class or tour with you?*

YesNoUnsure

Support Partner's Name:

First NameLast Name

Relationship to Support Partner:

Spouse/PartnerFamily memberFriendOther

In-Person Class Fee Total Collected:

In-Person Prenatal Class Fee - Total Amount Due:

USDPrenatal Classes (In-Person only)

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

How did you hear about this class/tour?*

May LVHN Parent Education programs contact you with future surveys?*

YesNo

By clicking the SUBMIT button, I agree to attend and participate in the class(es) and tour(s) scheduled. I also agree to give at least 48 hours’ notice should I need to reschedule or cancel by emailing ParentEd@lvhn.org.

LVHN Raising A Family - Prenatal Classes and Hospital Tours

Hospital Tours for Expecting Parents