EmailMe Form - Prepared Childbirth Class Registration

Name

First Last

Partner's Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Personal Information

Email

Phone

### - ### - ####

Estimated Due Date

Location Of Delivery (home or name of hospital)

Caregiver Name

Midwife

OB/GYN

Family Doctor/General Practioner

Labour Support Team

Where have you gotten most of your information about pregnancy/childbirth/
postpartum?

If you could only ask one question in this series what would it be?

Your biggest concern is.....

When you think about labour you wonder......

Do you want an Epidural or any pain medication?

yes

no

undecided

Do you plan to breastfeed?

yes

no

undecided

Class Selection

Please select the course session that you would like to attend. For private classes we will contact you directly to arrange a dates and times.

Traditional Class $225

October 7/14/21/28

November 4/11/18/25

December 2/9/16/23

Weekend Intensive Group Class (two days) $200

October TBA

November TBA

December TBA

Weekend Crash Course (one day) Group $150

October

November

December

Private Class

Workshop Selection Selection

Please select the workshop that you would like to attend. Workshops are $50/couple and 90 minutes in length.

Newborn Parenting 101

October 16

November 13

December 11

Sleep Nurturing for Newborns

October 9

November 6

December 4

How To Get Your Baby/Toddler to Sleep

October 23

November 20

December 18

Comfort Measures for Labour

October 30

November 27

December 20

Payment Information

Please indicate below how you wish to pay for your registration. Your registration will be considered complete when we have received both this form and your full payment. Payment must be received no later than two weeks before your class/worshop begins.

E-Transfer to leeanne@miabellamamma.ca

Cheque (please see mailing instructions below)

Paypal (you will receive an invoice)

Credit card (you will be contacted by phone for details)

Make cheques payable to LeeAnne Hamilton and mail to
1081 Dowland Crescent, Burlington, Ontario L7T 4C7

Referral Information