Lamaze Childbirth Education Class Registration Form

1

Pregnant Parent Name* This field is required.

First Name

Last Name

2

Preferred Name/Nickname and/or Pronouns

3

Partner Name

First Name

Last Name

4

Preferred Name/Nickname and/or Pronouns

5

Email* This field is required.

example@example.com

6

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

Phone Number* This field is required.

Please enter a valid phone number.

8

Estimated Due Date* This field is required.

Date

9

Primary Care Provider* This field is required.Please let me know who your Midwife or Doctor is.

10

Where are you delivering your baby?* This field is required.Please choose one option.

Please select one option.

11

If you are delivering in the hospital, please tell me which one.

13

Number of childrenHave you given birth before? If so, how many children have you had (not including this pregnancy)?

14

If you have given birth before, what have your experience(s) been like?

15

How did you hear about Mum's the Word?* This field is required.

16

What would you like to learn from our classes?* This field is required.Please share anything you would like to me know.

17

What are your hopes for your birth?* This field is required.

18

Please provide me with preferred days and times for classes.* This field is required.I will do my best to coordinate classes based on availability for all parties.

19

Please read these terms.

I am a Midwife and a Doula. There may be times where I am called away either before our class or during our class (if we are meeting for a live session in person or online). If this is the case, I will notify you via email and/or text message as soon as possible and will reschedule our live class as soon as I am able.

There are no refunds if you cannot make a class, if you have your baby early, or if we need to reschedule a class.

20

Please initial that you've read our terms.* This field is required.By initialing here, you agree that you've read and that you understand our terms.

Initial here.

21

Agreement to Terms* This field is required.By typing your name on the line below, you agree to our terms.

Please type your name here.

22

If you need a payment plan on the full fee ($500) please let me know how you would like to break it down. I ask that your fee be paid up by our final class together. If you need something different, please tell me here.

23

If you need a sliding scale AND a payment plan, please let me know the following: (1) your household gross monthly income, (2) the number of people in your household, and (3) the payment plan that works for you. I ask that your fee be paid up by our final class. If you need something different, please tell me here.

24

My Products

My Bag

0

Lamaze Childbirth Education Class (Paid in Full)This option allows you to pay in full.
$500.00Edit
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Lamaze Childbirth Education Class - Non-Refundable Retainer for Payment PlanThis option allows you to pay a non-refundable retainer of $100 to hold your place while also paying on a payment plan towards the full fee of $500. Please contact me for additional terms.
$100.00Edit
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Lamaze Childbirth Education Class - Sliding ScaleThis option allows you to pay a non-refundable retainer of $50 to hold your place while also paying towards your fee. Contact me to discuss your options for a sliding scale.
$50.00Edit
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Payment Methods

Credit Card

First Name

Last Name

Google Pay

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Apple Pay

After submitting the form, you will be redirected to the Apple Pay to complete the payment.