Coach's Name ( First and Last ) [your partner or the person attending class with you]
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Coach's Occupation
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Relationship with Coach (partner, husband, wife, mother, etc.)
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Coach's Phone
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Coach's Email
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Which email do you want me to use for class communication and updates?
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Address (Street, Apt. #, City, and Zip please) I am unable to get your Student Workbook from the Academy without this info. Thanks!
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Birth Attendant's Name (Midwife, OB)
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Where are you planning to give birth?
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Besides the medical team, who else will attend the birth?
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Are you planning to breastfeed your baby?
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How is your health status?
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Do you exercise regularly?
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If yes, what do you do?
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Have you had any problems with this pregnancy?
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Does anyone in your household smoke?
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Do you have other children? If yes, please write down their names and ages as well as any special information you would like me to know about their births.
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What are you are hoping to experience for your birth?
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What would you like to get out of this class?
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Do you have any special concerns, fears, or circumstances you would like me to know about so that I can be sure to meet your needs during this course? (Please be assured that anything you write is confidential and will not be shared with anyone.)
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How did you find out about this course?
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Thank you for filling out this registration form. I will be in touch with you soon! Warmest, Susan
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