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

Sunday December 5, 10:30am-1:30pm
Sunday December 12, 10:30am-1:30pm
Venue: Knocknacarra Community Centre, Cappagh Road, Galway

Optional at no extra charge: "More on Breastfeeding" workshop on Zoom Tuesday, Dec 14th 7-9pm

**Places are limited**
 
The fee for the course is €160 (pregnant person + partner) which includes a 1-year Cuidiú membership and ongoing phone/email/Cuidiú group support. To book, please complete this form and pay a €50 booking fee to guarantee your place; the remainder (€110) will be due at or ahead of the first class. Payment details are below. Thank you.

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Email *
Name
Address
Phone number
Email
Will your partner or birth companion attend the session with you?
Clear selection
If yes, partner/birth companion's name
Companion's email
Your baby's estimated birth date
MM
/
DD
/
YYYY
Planned place of birth
Type of care (eg., midwives clinic, community midwife, private consultant, etc):
Is this your first baby?
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Have you experienced a previous miscarriage or stillbirth?
Have you had any medical conditions or difficulties with this pregnancy?
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, and to arrange Cuidiú meet-ups such as a postnatal reunion for those who took classes with you or around the same time. Your information will not be shared without your consent. Do you consent to this use? *
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? *
Will you be paying by Bank Transfer or PayPal? *
Any other comments
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