Class Registration Form

Please fill in all fields.

Title:	Select One Mr. Mrs. Dr. Prof. Ms. Rev. Miss
First Name:
Last Name:
Address:
City/Town:
Province:	Please Select Alberta British Columbia Manitoba Newfoundland/Labrador New Brunswick Northwest Territories Nova Scotia Nunavut Ontario PEI Quebec Saskatchewan Yukon Territory
Postal/Zip Code
Phone Number:
Email:
Class Name:	Choose Class Inspired Childbirth Preparation Private Class $175 Inspired Childbirth Preparation $125 The Second Time Around $75 The Second Time Around Private Class $125 Sibling Prep Private Class $50 Private Refresher/VBAC Class $100 Pre & Post-Natal Yoga Class $80
Date of Class Series:	Choose Date Inspired Childbirth Preparation Private Class ↓ Inspired Childbirth Preparation Six Week Series ↓ January 9th to February 13th 2012 March 7th to April 11th 2012 April 16 to May 28 2012 June 4th to July 9th 2012 July 23rd to August 27th 2012 September 6th to October 11th 2012 October 24th to November 28th 2012 November 6th to December 11th 2012 ↓ Inspired Childbirth Preparation Weekend Classes ↓ February 4th and 5th 2012 March 24th and 25th 2012 April 28st and 29th 2012 June 16th and 17th 2012 August 17 and 18 2012 September 15 and 16 2012 October 20 and 21st 2012 ↓ Early Expression ↓ Tuesdays Oct 25, Nov 1, Nov 8, Nov 15 Tuesdays Nov 22, Nov 29, Dec 6, Dec 13 Thursdays Oct 27, Nov 3, Nov 10, Nov 17 Thursdays Nov 24, Dec 1, Dec 8, Dec 15 ↓ The Second Time Around ↓ December 10th 2011 Sibling Prep Private Class
Who will be accompanying you to class?	No accompaniment
Do you plan to have any additional Labour Support?	Yes No If so, who?
Due Date:
Caregiver (doctor or midwife):
Baby’s Expected Place of Birth:
Mother's age:
Number of Previous Births:
Numbers & Ages of Children:
Are you planning:	An unmedicated birth? To breastfeed?
How did you hear about MACFE Prenatal Classes?
Have you attended prenatal classes before?	Yes No If so, where?
What topics are you concerned about and therefore would like to see covered in class?
Do you have any concerns regarding your pregnancy? Give details if you wish.
Do you have any concerns regarding labour or birth? Give details if you wish.
Have you read any books about childbirth or childcare, which you found useful? (Please list)
How will you be paying?	Mail in payment PayPal
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