Contact Information
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Mother's Name:
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Partner's Name:
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Relationship of Partner to Mother:
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Address 1:
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Husband
Life Partner
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Other (specify):
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Fiance
Friend
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Address 2:
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City:
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Mother's birth date (mm/dd/yyyy):
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State:
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Zip:
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How did you find Birthing Baby?
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Home
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Phone 1:
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Cell
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Work
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Friend
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Name of referral source or
search engine:
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Work
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Home
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Cell
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Phone 2:
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Midwife/Doctor
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e-mail:
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Internet search
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Your confirmation will be sent to the email address you provide above.
*** Please double check that it is correct. ***
Confirmation is usually sent within a few hours, but occasionally it can take up to 48 hrs. Please
add sherry@birthingbaby.com to your address book to avoid delay in receiving your confirmation.
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Pregnancy and Birth Information
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This will be the mother's
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Due Date (mm/dd/yyyy):
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Name of Hospital, Birth Center or Home Birth Service:
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Name of Midwife or Doctor planning to attend:
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The birth attendant is a:
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Other services interested in:
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Homebirth
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Doula
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We plan to
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Is there anything you wish to let me know about a previous pregnancy and/or birth experience?
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Any complications with this pregnancy?
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Any concerns, fears or questions?
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Choose Your Class Dates
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Birthing Baby Complete Childbirth Class Series dates:
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Amount Due
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Birthing Baby Complete Childbirth Class Series
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We qualify for the Early Registration Savings of $15.
(What's this?)
We do not qualify for the Early Registration Savings.
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Subtract any savings you qualify for from the regular $400 fee. Select the total fee for
your Birthing Baby Complete Childbirth Class Series in the box to the right. This fee
includes the $50 non-refundable deposit.
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TOTAL DUE:
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Payment Options
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Please select one of the following:
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Online full payment
Mail full payment
Online $50 non-refundable deposit to reserve our spot
Mail $50 non-refundable deposit to reserve our spot
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Payment Methods
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Personal Check, Money Order and Cash Payments - If you prefer to mail in your payment or
pay cash in person, complete your registration by clicking the "Register" button once. A screen will
appear which will confirm your registration was sent. I will contact you by email within 48 hours to
confirm your registration and payment method.
Credit or Debit card Payments - You can use PayPal to pay online with a credit card or debit
card. You do not have to create a PayPal account to do so and it does not cost you anything to
use this service. (I pay a 3% fee to receive the funds).
To complete your registration and pay online, click the "Register" button once. You will
then be able to pay online.
If the "Register" button does not show below, press "Enter" on your keyboard to register.
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