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Space 2 Flourish Prenatal Class Registration
Contact info:
Carmen Ohori
(250) 640-0678 mobile
carmen@space2flourish.ca
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Personal Information
Helping us learn about you will make for a rich and productive learning environment as you prepare for your birthing journey.
Birthing Person's Full Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Partner/support person
Your answer
Partner/support person Phone Number
Your answer
Due date
MM
/
DD
/
YYYY
How many pregnancies have you had?
*
Your answer
Have you experienced any pregnancy loss?
*
Choose
Yes
No
Unsure
Can you please briefly share any current or past pregnancy complications (including loss)?
Your answer
Any allergies?
*
Your answer
Can you briefly share any specific topics you are hoping to learn about?
Your answer
Where do you plan on birthing your child?
*
Home Birth
Hospital Birth
Undecided
Other:
On a scale of 1 to 10 how much do you know about pregnancy?
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1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 how much do you know about labour and birth?
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1
2
3
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5
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7
8
9
10
On a scale of 1 to 10 how much do you know about breastfeeding/chestfeeding?
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1
2
3
4
5
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8
9
10
On a scale of 1 to 10 how much do you know about newborn care?
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1
2
3
4
5
6
7
8
9
10
Do you have any concerns about the prenatal class or personal matters you think Carmen should be aware of?
*
Your answer
Thank you!
You are welcome to contact Carmen if you have any questions or concerns about this program. I look forward to meeting you.
carmen@space2flourish.ca
(250) 640-0678 mobile
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