Penny Simkin's Childbirth Class Info Sheet

Class Start Date Class Start Date * / MM / DD YYYY
Name Name * First Last
Phone Phone * - ### - ### ####
Mother's Age
Email *

Please use an email you will check after baby arrives.
Occupation *
Partner's Name Partner's Name First Last
Partner's Phone Partner's Phone - ### - ### ####
Partner's Email

Please use an email you will check after baby arrives.
Occupation
Due Date Due Date * / MM / DD YYYY
Care Provider *

Doctor or midwife name
Planned Birth Location *
Number of Previous Pregnancies *
Have you given birth before? *

Have you given birth before? Yes No
Please briefly describe your previous birth(s). Please include names and ages of children.
Why did you decide to take this class? *
List three topics of special interest or concern that you hope to learn in this class. *
Do you have any conditions that could affect this pregnancy and birth that you would like the instructor to be aware of? (Examples: high blood pressure, diabetes, history of miscarriage) *

Do you have any conditions that could affect this pregnancy and birth that you would like the instructor to be aware of? (Examples: high blood pressure, diabetes, history of miscarriage) Yes No
Please describe.
Are you planning to work outside the home after baby is born? *

Are you planning to work outside the home after baby is born? No Part Time Full Time
How soon after the baby's birth?
We are considering creating Facebook Groups to facilitate class discussion and interaction. Is this something you would be interested in? (Instructions will be provided at a later date)

We are considering creating Facebook Groups to facilitate class discussion and interaction. Is this something you would be interested in? (Instructions will be provided at a later date) Yes No
May we include your name and contact information in our class roster (available to class members only)? *
Please sign indicating consent to share contact information with the class. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.