Mothers Birth -- BFW Registration

Your Full Name:
Occupation:
Your Birth Date:

Partner's Full Name:
Occupation:
Partner's Birth Date:

Expected Due Date:
Preferred Class Location:	Provo Park City
Preferred Start Date:
Home Phone:	()-
Other Phone:	()-

Mailing Address w/ Zip:
Email Address:

Physician/Midwife:
Planned Birth Location:
Have you hired a doula?	Yes No
If yes, who?

Other Children:
Name:
Birth Date:
Name:
Birth Date:
Name:
Birth Date:

Please list any complications or interventions with previous pregnancies or labors: (miscarriage, ectopic, pre-eclampsia, multiples, epidural, forceps, cesarean, episiotomy, etc.)


How did you hear about my childbirth classes?

Do you have any special needs regarding learning style that I should know about?

Please indicate anything else you would like me to know:

This is a "mail to" form. Hitting the register button will open a window in your mail program with this information in the message box. Simply click send and I will receive your registration. Once you have paid your fee (see payment options below), you will be fully registered. I'm thrilled to be part of your preparation for your birth!

Payment Options:

1. By Mail:

Please mail a check payable to Heather Duncan to:

Heather Duncan
1224 South 760 West
Provo, Utah 84601

2. Pay with Paypal

Paypal.com is an easy and safe way to send money over the internet.

Notice: Paypal charges me a 3% fee to take payments by credit card. I am happy to cover this charge as part of your class fee. If, however, you need a refund for any reason, this fee (between $6 and $7.50) will be deducted from your refund.

Class Menu

Gourmet 6 Week Series and Weekend Retreats

$185 per couple*

Delectable Private Classes

$250 per couple*

Monthly Red Tent Circles

Free

*A couple can be a woman and her husband, partner, mother, friend or doula. All types of birth partners are welcome and classes are designed to meet both the mother's and the father's/birth partner's needs.