Name

First Name

Last Name

Number

Estimated Delivery Date

YYYY

You are welcome to attend this course on your own. If others are joining you, please tell us their names and their relationship to you.

Where do you expect to give birth?

At home

Hospital

Other

Who is your care provider?

Doctor

Midwife

I don't have one

Where did you hear about this class?

Do you have any accessiblity needs you would like us to know?

Would you like to share anything else about yourself or your pregnancy?

I have sent an e-transfer or Paypal payment of $50-$150 to nestingdoula@gmail.com to confirm my registration.

Yes

I request a subsidized spot