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Full Name:
Email:
Partner’s Name (if applicable):
Street Address:
City:
Province:
Postal Code:
Phone Number:
Due Date:
Where are you having your baby?
Where are you having your baby?
Markham Stouffville Midwifery Alongside Unit
Markham Stouffville (OB unit)
The Scarborough Network – General
The Scarborough Network – Birchmount
The Scarborough Network – Centennary
Which Program did you want to register for?
Which Program did you want to register for?
Training Program ($300)
Experienced Doula Program ($1050)
Unsure at this time
Doctor’s name or midwife practice:
Is this your first baby? If no, please list the number of previous births:
Please tell us your age:
Do you speak English? Please list other languages you speak:
Do you want to Breastfeed your Baby?:
Do you want to Breastfeed your Baby?:
Yes
No
Unsure at this time
Do you have plans for the use of medications in labour? Please tell us your thoughts. It’s ok if you aren’t sure:
Do you have any health issues or cultural issues that we should know about? If so, please tell us so we can do our best to accommodate them:
I agree to the terms of service, including the cancellation policy found here: birthdoulaprogram.ca/terms
I agree to the terms of service, including the cancellation policy found here: birthdoulaprogram.ca/terms
Yes
No
Anything else you’d like to share with us:
SUBMIT
