Birthing Baby Online Childbirth Class Registration Form

Class Registration

Contact Information

Mother's Name:

Partner's Name:

Address 1:

Relationship of Partner to Mother:

Husband
Life Partner

Fiance
Friend

Other (specify):

Address 2:

City:

Mother's birth date (mm/dd/yyyy):

State:

Zip:

Phone 1:

Home

Cell

Work

Phone 2:

Home

Cell

Work

e-mail:

This is the email address your confirmation will be sent to. 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.

Pregnancy and Birth Information

Due Date (mm/dd/yyyy):

This will be the mother's

Name of Hospital, Birth Center or Home Birth Service:

Name of Midwife or Doctor planning to attend:

The birth attendant is a:

Planning on having a doula?

We plan to

Is there anything you wish to let me know about a previous pregnancy and/or birth experience?

Any complications with this pregnancy?

Any concerns, fears or questions?

Choose Your Class Dates

Birthing Baby Complete
Childbirth Class Series
dates:

Amount Due

Birthing Baby Complete Childbirth Class Series

We qualify for the Early Registration Savings of $15.
(What's this?)

We do not qualify for the Early Registration Savings.

Subtract any savings you qualify for from the regular $300 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.
TOTAL DUE:

Payment Options

Please select one of the following:

We will be mailing the full payment for the Birthing Baby Complete Childbirth Class
Series. See box above for the total amount due.

We will pay the full amount of the Birthing Baby Complete Childbirth Class Series
online today. See box above for the total amount due.

We will be mailing the $50 non-refundable deposit to reserve our spot in the Birthing
Baby Complete Childbirth Class Series.

We will pay the $50 non-refundable deposit to reserve our spot in the Birthing Baby
Complete Childbirth Class Series online today.

Payment Methods

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.