My Birth Toolkit Enrolment Form

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Please fill out the form below to enrol. If you have any questions feel free to contact me via email or phone.

Christa Buckland
BHlthSc (Health Promotion)
Doula, Hypnobirthing, Online Programs
0422 229 312
christabuckland@outlook.com
www.ChristaBucklandDoula.com

Email *

Course Enrolment

Mother's Name *

Mailing Address *

Preferred Phone *

Estimated Due Date (EDD) *

YYYY

Birth Companion Name *

Relationship to you (e.g. spouse, partner, doula etc.) *

Intended place of birth (name of hospital, birth centre or home)

Care Provider Name and Title (e.g. Obstetrician or Midwife)

Is this your 1st, 2nd, 3rd etc. baby? *

Is this birth a VBAC (Vaginal Birth After Caesarean)? *

Yes

Would you like the session conducted in your home or Christa's home?

In your home

In Christa's home (Mount Annan)

via Zoom online conferencing

Other:

Clear selection

If you selected Christa's home in the above question: In order to ensure that I can provide a safe and comfortable environment for you please let me know if you have any dietary requirements or allergies.

Is there any important information you wish me to be aware of before classes commence?

How did you find out about my classes? *

Facebook

Friend

Google

My website

Other:

Required

Tuition Fee: $500 6-hour private session (plus travel fee)

Fee includes your workbook and ongoing support.
Payment plan available for clients with limited income.
To confirm your booking please submit this form with a $100 non-refundable tuition deposit.
Final payment is due no later than 7 days prior to course start date.
***Please note: Cancellations/refunds cannot be accepted within 7 days of the course start date. At this time, refund (of the $400 balance) can only be given in exceptional circumstances.***

Travel fee: A $50 travel fee applies if you are located more than 30 mins from Campbelltown.

Payment can be made via PayPal (preferred) or direct deposit.

Please pay via this PayPal link: (preferred)
https://www.paypal.me/ChristaBuckland

OR

Direct Deposit Details:
Bank: Commonwealth Bank
BSB: 062-692
A/C: 37571348
Name: Christa Buckland

A copy of your responses will be emailed to the address you provided.

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