Class Registration Form

Birthing From Within® Registration Form

* Indicates required field

Choose your class date(s) here: *

Are you registering as a couple? *

Yes, we are both attending No, I am registering as a single attendee

Estimated Due Date *

Who referred you to these classes? *

Your Name *

First

Last

Your preferred pronouns *

Partner's Name *

First

Last

Your partner's preferred pronouns *

Your Email *

Your Phone Number *

Partner's Email *

Partner's Phone Number *

Your Occupation *

Partner's Occupation *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preferred Method of Communication *

Care Provider for this pregnancy *

Planned Place of Birth *

What are you hoping to learn in these classes? *

Are you interested in Doula support? *

Payment method *

Email transfer (to kimberly@lunamama.ca) Credit Card (invoice sent upon form submission) Pre-arranged payment plan

If you have food allergies or dietary restrictions please list them below *

Once I have received this form an invoice will be sent to you. Payment is required to complete your registration and guarantee your spot.

*Cancellation of enrollment must be received two weeks prior to the start date of the class to be considered for refund. Refunds are made on a case by case basis. Refunds are not available once classes have begun.

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