Birthing Yourself Registration Short Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form is for PPN Students and returning Birthing Yourself participants. If this is your first Birthing Yourself workshop, please complete the Birthing Yourself Long Form instead.

To register for other classes or PPN visit these forms:
RiverBluff Sanctuary Class Registration
PPN 2-Year Study Group

FACILITATORS:

Janet Evergreen, MA
(434) 906-4181
janet@janetevergreen.com
www.janetevergreen.com

Tonya Ridings, LCSW
(434) 465-1561
tridings23@gmail.com
www.tonyaridings.com

PAYMENTS:

After completing your registration form, your payment confirms your spot. We prefer payment by Venmo, Zelle, or check:

Venmo @Janet-Evergreen
Zelle to janet@janetevergreen.com
Check to Janet Evergreen 115 RiverBluff Circle, Charlottesville, VA, 22902.
To pay via PayPal, credit card, or debit card, got the the "Classes" page on Janet's website: www.janetevergreen.com/classes. Scroll down to specific class and click the "Payment" button.

REFUND POLICY:

If the workshop/class is more than a month away and we can refill the spot, we are happy to give a full refund minus $50. Less than a month away, no refunds will be given unless your spot fills.

Email *

Basic Information

All information is completely confidential. If you are uncomfortable responding to any of these questions, email or telephone Janet or Tonya for support.

Date and Location of this Process Workshop *

Name *

Telephone Number *

Address *

Birthdate and Age *

Familial Status (i.e. married, partnered, single, divorced, children, grandchildren...) *

Occupation *

Emergency Contact: Person and Phone Number *

Dietary Needs or Restrictions:
Optional lunches and snacks provided for $45 to cover supplies. Currently Howie volunteers cooking.

You may donate to INEPE Community School in Ecuador to thank Howie and support the students.
*

I will pay $45 to have lunches and snacks provided

I will provide my own snacks and meals

Other:

Lodging: I intend to stay at _________________.
Where will you stay during this retreat?

Heartsong Sanctuary (location of retreat, Geoff’s home)

Wren House (Tonya’s) $50 per night + share of $220 cleaning fee

Other:

Required

Lodging: I intend to stay for _________________.
What are your days of arrival / departure?

Communication Preferences
Check all that apply.

Yes, you can text me.

Yes, you can share my phone and email contact with the group.

Other:

Required

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms