Register - The Birth Doula Program

Name*

First Last

Email*

Partner's Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Due Date*

Where are you having your baby?*

Which Program did you want to register for?*

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 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-of-service

Anything else you'd like to share with us:

Welcome!