Registration Form

Registration Form

Beautiful Bumps Kalgoorlie
Participant Details:
Full Name:*

First NameLast Name
Preferred name:
Age:
Gender:
Phone Number:*
E-mail:
example@example.com
Ethnicity/ nationality:
Please select:

AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait IslanderNone of the above
Relationship status e.g. single, coupled:
Do you require creche services? If yes – how many children and what ages?
Allergies/ dietary requirements:
About your pregnancy:
When is your expected due date:

DayMonthYear
Date
Are you currently accessing pre natal support?

YESNO
Where do you access pre natal support?

Population HealthLocal General PracticeBega Garnbirringu Health ServiceDiabetic EducatorKalgoorlie Regional HospitalParent ServicesOther
At the event:
I am interested/ would like to enrol in the following:

Belly paintingBelly castingPregnancy yogaCraft activties
Consent and permissions:
I consent to the information I have provided on this form to be stored, and agree to the use of de-identified information collected for evaluation, research and/or promotional purposes by Beautiful Bumps Kalgoorlie

YESNO
I give permission for photographs and video of myself and/or my children to be taken used for Beautiful Bumps Kalgoorlie promotional purposes (including website, flyers and/or social media)

YESNO
I give permission for my details to be used to contact myself about future Beautiful Bumps Kalgoorlie sessions, courses and events or other workshops via electronic mail or SMS

YESNO
Thank you

More information to come regarding this event. Monitor your emails and phone for more updates to come!

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How did you hear about us?*
Please Specify*
Any further questions/ concerns regarding Beautiful Bumps.
Should be Empty: