Prepared for Birth Registration Form

Prepared for Birth Registration

Starred items are required information. Please look for a "Thank You" message after submitting your form to show that it has been properly completed.
Pregnant person's name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Phone Number*

Area CodePhone Number
Email address*
Estimated Due Date*

MonthDayYear
Current prenatal Care Provider*
Intended Birth Place*
How did you hear about this class?
Partner's Name
Partner's Phone Number

Area CodePhone Number
Is there any special information you would like to share with me? (Health concerns, allergies, special considerations, etc.)
Pregnant person's pronouns
Partner's pronouns
For which series are you registering?*
What is your number one goal for this class?
Deposit/Payment
The class fee is $175 unless other arrangements have been made.

Payment may be sent via PayPal.me/JennyCHoffmann

(You don't have to have a PayPal account to use it.)

Please be sure to put your name and class for which you are registering in the memo with your payment. Payments made "to friends and family" will not incur fees.

If you do not wish to pay through PayPal, you can email me for cash/check payment options.

Your spot in class will not be reserved until your payment has been received.
By signing, I acknowledge that I understand part or all of the class series may be held virtually over Zoom based on personal or community wide risk factors for viral transmission. I understand that this decision is up to the discretion of Jenny Claire. I also agree that my class partner and I will wear masks covering our mouths and noses for any In-person sessions, and that we will not attend class in person if we are symptomatic or positive for COVID. Failure to respect these guidelines for the safety of all participants may result in being excluded from class. Fees paid are not refundable. *

Clear
Should be Empty:

Prepared for Birth Registration

Deposit/Payment