Bean Family Wellness - Prenatal Class Registration Form

www.beanfamilywellness.com | 204-990-3519 | info@beanfamilywellness.com
To reserve an appointment for a group or private prenatal or refresher childbirth class, please fill out the Bean Family Wellness Prenatal Class Client information form. The information on this form will be kept confidential and only shared with your childbirth educator. This information will help your instructor keep track of your information so that she is better able to educate you are personalize the content for your class.

Bean Family Wellness is happy to offer both group, private, and specialty focused childbirth classes! These classes cover a variety of topics. Classes are designed for couples, or single parents with their doula or other support person. Because of the individual nature of private classes, they will also be customized to your past experience, knowledge, and hopes for your pregnancy, birth, and postpartum experience. For group classes, this information will help to tailor the class to the questions of the families registered.

Bean Family Wellness classes are great for anyone planning a hospital, home, or birth centre birth, either with an obstetrician (OB), family doctor, or midwife. Bean Family Wellness classes are inclusive and welcome all families.

Please note that prenatal classes do not replace information from your care provider. All questions or concerns for yourself or your baby related to pregnancy, labour, or postpartum must be forwarded to your care provider.

Notes:
-Class price includes up to 2 participants (couples, or single parents with one support person).
-50% of your payment acts as a class retainer and is non-refundable. This is to ensure that all people who wish to enroll in Bean Family Wellness classes are given the opportunity to participate, and avoid last minute cancellations and changes.
-100% refunds will be provided only the case of a miscarriage or giving birth prior to the beginning of your prenatal class/classes.
-21 days notice is required for class cancellations (refund of 50% of your total fee) or rescheduling. Less than 21 days notice for rescheduling is based on availability. Refunds will not be provided for cancellations with less than 21 days notice.
-Bean Family Wellness uses various locations in Winnipeg for our classes. Most are in the South, West or Central parts of Winnipeg. Your instructor will email you 2 weeks prior to your class, once final participant numbers have been confirmed, with the exact location and address of your class.

*Please contact us with any questions regarding these policies.*
Prenatal Class Client - General Information
First Name:
Last Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred first name (if applicable):
Date of Birth:
Phone Number (best number to reach you):

Area CodePhone Number
E-mail Address
Marital Status
Your partner's name:
Will your partner be attending classes with you?
Who do you plan to have present with you during your birth?
Do you have a doula?
How did you hear about Bean Family Wellness?
GROUP Prenatal Class Options

Only complete if you wish to register for a GROUP class.
I want to register for a GROUP PRENATAL weekend class - $185 + gst (per couple):
I want to register for a GROUP PRENATAL evening series class - $185 + gst (per couple):
PRIVATE Prenatal Class Options

Only complete if you wish to register for a PRIVATE class.
I want to register for a Customized PRIVATE PRENATAL In-home Class - $215 + gst (per couple):
If you have already reserved a class time, please ignore this area of the questionnaire and continue to 'Pregnancy Information and History'. Thank you.
I am available for my PRIVATE class during:
Please indicate any days of the week that you are unavailable.
Please indicate if you are hoping to reserve a specific date.
Pregnancy Information and History
Current number of weeks pregnant:
Estimated Due Date

MonthDayYear
Number of previous pregnancies:
Number of previous births:
Ages of other children:
Type of care provider (OB, Family Doctor, Midwife, other)
Planned Place of Birth
Please describe your hopes for your birth and postpartum experience:
Do you have any issues, fears, or phobias around this pregnancy / birth / postpartum experience?
List the things you are most excited for during your pregnancy, birth, or postpartum experience.
Postpartum
Do you plan to breastfeed?
Do you anticipate any issues breastfeeding? If so, please explain.
Do you have any specific questions / topics you'd like to learn more about in terms of baby care? If so, please explain.
Do you have any concerns about the postpartum period (including but not limited to emotional, physical, or social supports)? If so, please explain.
More information
Please list any books that you've read about pregnancy, birth or postpartum so far:
Please list any videos / documentaries that you've watched about pregnancy, birth or postpartum so far:
What do you hope to gain from taking a prenatal class?
Is there anything else you would like to share about your family?
Additional Comments:
Reserving Your Class & Payment Selection
Below, please choose the type of prenatal class that you would like to register for and how you would like to pay for your class. Select an option below to pay now directly through PayPal, or choose another payment method type that works best for you.

If you choose another method of payment, following submission of this form, you will receive an invoice reflecting your chosen form of payment.

Please note that because limited spaces are available for classes each month, class registration cannot be confirmed until your payment is received.

For more information, or for questions, please contact Ilissa, owner of Bean Family Wellness, at 204-990-3519 or info@beanfamilywellness.com.

Class Payment (Select one option)

PRIVATE Prenatal Childbirth Education Class $215.00 CAD

GROUP Prenatal Childbirth Education Class$185.00 CAD

PRIVATE *Refresher* Prenatal Childbirth Education Class$150.00 CAD

I would like to choose another method of paymentFree

Payment Options

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Subtotal Tax Total $0.00 CAD

By signing below, I agree to the terms listed and understand that prenatal classes are for general introductory information about pregnancy, labour, comfort measures, birth, postpartum, and care for families and babies. Bean Family Wellness prenatal classes do not replace information from your health care provider/s. Any concerns or interventions related to your pregnancy or your baby should be discussed in full with your health care provider/s (including but not limited to benefits, risks, and alternatives). Bean Family Wellness will provide general information and resources however, cannot provide advice or recommendations on what is best for your individual family or situation.
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Prenatal Class Client - General Information

GROUP Prenatal Class Options

PRIVATE Prenatal Class Options

Pregnancy Information and History

Postpartum

More information

Reserving Your Class & Payment Selection

Class Payment (Select one option)