Private Course Registration Form

To be completed by both attendees if possible
All information is strictly confidential

Personal Information
Mum's Details
Mum's Name*
Date of Birth*
Occupation*
Partners's / Class Companion's Details
Partner's / Class Companion's Name*
Date of Birth*
Occupation*
Other Personal Details
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Personal Email*
Mobile Number*

General Information
How did you hear about She Births®?
- Yoga
- Google
- Natural Therapist
- Friend
Referal Name

Provide their name if possible
Please describe your feelings about this approaching birth and parenthood*
What do you hope to gain from the She Births® course?*
Have you done any other childbirth preparation classes?*
Please describe your favourite place in nature*
What do you enjoy doing?*

Pregnancy Details
Estimated Due Date*
Date Format: DD slash MM slash YYYY
Gestation at time of course*
Birth location*
delivery suite / birth centre / home
Caregiver's details and name
team midwifery / GP shared care / obstetrician / public / private / independent midwife
Doula's name
if applicable
Are your caregivers supportive of the She Births® classes?*

Preferred Course Dates
Private courses are taught over 2 x 3.5hrs. Held on Tuesdays, Wednesday or Thursday every fortnight. Times are 12-3.30pm or 4-7.30pm. Please let us know what you prefer and we will try to accommodate.
First Preferred Course Date
Date Format: DD slash MM slash YYYY
Second Preferred Course Date
Date Format: DD slash MM slash YYYY
Preferred Educator (If Available)
If your preferred educator is not available then we will help you find the best She Births to suit your needs
Email
This field is for validation purposes and should be left unchanged.

Personal Information