Birthing Yourself Registration Long Form

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This form is for first time Birthing Yourself participants. If you have already participated in PPN or a previous Birthing Yourself workshop, you can use this Birthing Yourself Short 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

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

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