Center Song Childbirth Class Registration

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Registration for Center Song Clients

Email *

Name Cell Numbers and Email Addresses of Birthing Parent *

Occupation Birthing Parent

Name, Cell Numbers and Email Addresses of Support Partner (if applicable) *

Occupation of Support Partner *

Mailing Address *

Estimated Due Date *

YYYY

Planned Birth Place, State/Province and Name of Provider or Facility *

Name and Location of Facility (Please Include State/Province and Type of Facility) *

Name of Provider *

Have you *ever* taken another childbirth class/preparation program? If so, for this pregnancy or a previous one? *

Yes

One of us has in our family, not both of us

Yes, a hospital birth class for this pregnancy

Yes, a hospital birth class for a previous pregnancy

Yes, I took class with another independent educator for this pregnancy

Yes, I took a class with another independent educator for a previous pregnancy

Yes, I took a class with Maura Jo

Other:

Name of Childbirth Program You Prefer to Take (Evidence Based Birth(R), Hypnobirthing and Mindset, Birth Basics, etc.) *

Start Date of Childbirth Program *

YYYY

Do any of these categories apply to you/your family?

BIPOC

LGBTQ+

Other:

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Do you currently have a doula hired? If so, who are you using? Are you thinking of getting one? If you are interested in adding Virtual Doula Services on to your ticket, please reach out to MJ for a consultation appointment. *

Whom may we thank for referring you to Center Song? (name and email please)

Any questions, needs or concerns before we get started?

Submit

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