Birthing From Within Registration Form
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| Preferred Start Date
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2011 Sept 18-Nov 6 (no class Oct 9) - Templeton Community Centre 2011/12 Nov 14-Jan 9 (no classes Dec 19-26) - Adar Birth Services 2011 Feb 13-Apr 16 (no classes Mar 5, Apr 2-9) - Adar Birth Services We recommend that you choose a class that finishes three to six weeks before your estimated due date.
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| Mother's Name
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| Date of Birth
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| Occupation
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| Phone 1
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| Phone 2
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Please make it easy for us to get ahold of you should we need to.
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| Email
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| Partner's Name
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| Date of Birth
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| Occupation
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| Phone 1
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| Phone 2
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Please make it easy for us to get ahold of you should we need to.
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| Email
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| Home Address
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| Estimated Due Date
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| Is this your first pregnancy?
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Yes No
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| If no, what was the outcome of your previous pregnancy/pregnancies?
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| Are you carrying multiples?
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Yes No
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| Where do you plan to give birth?
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Home BC Women's St Paul's Richmond Lions Gate Royal Columbian Burnaby General Surrey Memorial
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What is (are) the name(s) of your primary prenatal healthcare provider(s)?
Please also indicate their profession (midwife, OBGYN, GP) and their clinic name (if applicable).
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| How you are feeling about your pregnancy right now?
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| Tell me about some of your fears around the birth.
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If you can't think of any fears, please tell me what things you may have heard from other parents about their birth that has made you feel badly for them.
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| What books have you read, or are planning to read?
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| Please tell me what else you would like me to know to help get everything you need from your Birthing From Within classes.
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| How did you hear about us?
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