Cuidiú Antenatal Ireland (Galway) Booking Form (1:1 course)
Cuidiú Antenatal Ireland Small Group Course with Tara Durkin, Doula Next Door Galway
www.doulanextdoor.ie • www.antenatalireland.ie • 086.232.8229

Date: Sunday June 12th 2022, 2-6pm
Location: Yoga Sarsana, The Old Driving Range, Salthill
 
Course fee: €180 (pregnant person + partner) Includes 1-year Cuidiú membership. €50 booking fee or option to pay in full at booking. Payment details are below.

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Email *
Name and pronouns (e.g. she/her, he/him, they/their) *
Phone number
Email
Will your partner or birth companion attend the sessions with you?
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If yes, partner/birth companion's name and pronouns (e.g. she/her, he/him, they/their) & relationship (e.g. partner, doula, friend, mother)
Companion's email
Your baby's estimated birth date
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Is this your? *
Pregnancy Type *
If multiples please describe type (eg, fraternal, identical, shared placentas and/or amniotic sacs)
Planned place of birth
Type of care (e.g. midwives clinic, SECM midwife, private midwife, private consultant, etc):
Please share any information you feel may be relevant to your participation in the class or in relation to your pregnancy (e.g. pregnancy/birth history, maternal age, any access/dietary/language/learning needs). Additional information can also be sent via email if preferred.
Any further information, or anything you would like to add?
Is there anything you particularly wish to cover during the course?
Where did you hear about the classes? If Cuidiú website, how did you hear about Cuidiú?
Data Protection: Your email address will only be used to send you links to articles and handouts as part of the course material. Your information will not be shared without your consent. Do you consent to this use? https://www.cuidiu.ie/dataprotection *
Data Protection: There is an offer of one-year’s Cuidiú membership, free with the antenatal course fee. Do you give permission for your contact details (name, email, mailing address and phone number) to be sent to the Cuidiú national membership secretary to avail of membership? https://www.cuidiu.ie/dataprotection *
If you are NOT a current Cuidiú member and availing of the membership offer, please provide postal address to process membership to your local branch.
Will you be paying by Bank Transfer or PayPal? *
Any other comments
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