This form is only for registering for classes with Nancy & George Berntsen, AAHCC, serving the greater Bridgeport and New Haven areas of Connecticut.
Do not use this form for other's childbirth classes.

All Information submitted will be kept confidential. It will not be shared with anyone other than American Academy of Husband-Coached Childbirth (AAHCC)
a.k.a, The Bradley Method® of Natural Childbirth (http://www.bradleybirth.com)

You will be re-directed to a confirmation page instructing you how to send your registration deposit (via paypal or snail mail) if you have not already done so.

Series Start Date:      Today's Date:  

Email:
           Please make sure your email address is correct.

Mom: Last Name                        First Name
      

Due Date:  

Baby's Gender: Please select one: unknown or prefer not to disclose male female multiple birth

Home Phone:  

Mom Phone: (specify cell &/or work)  

Dad or Coach Phone: (specify cell &/or work)  

Dad or Coach's Last Name:                 First Name:
            

Your Full Address:
 

In the event that we need to contact you quickly (i.e., if classes are cancelled due to bad weather, sickness, emergency,)

Is it o.k. to contact you via private message on facebook?
   Mom: yes      Facebook name & network or school:
   Dad: yes       Facebook name & network or school:

Is it o.k. to send you short text messages via your cell phone?
   Mom: yes (short text messages to cellphone is okay)
   Dad: yes (short text messages to cellphone is okay)

Additional information:

Name of Doctor or Midwife or Practice:
 

Years Married if applicable:      Ages of other children:  

How  did you hear about these classes?
 

Mom's Birth Date:  

Mom's Height:      Mom's Usual Weight:  

Her Occupation
 

Mom's Health Status:  

Smoker? Yes     No

Dad's Birth Date:  

Dad's Height:      Dad's Weight:  

Dad's Occupation:  

Dad's Health Status:  

Dad Smokes? Yes    No

Coach:

Who will be the coach?  

Relationship:  

Will you take pictures?  

Besides the medical team who else will be attending the birth?
 

Are you planning to breastfeed your baby?  

Have you contacted La Leche or other?
 

What physical activities have you engaged in regularly?
 

Childbirth History

# other children you have:         

# medicated:       # cesarean:     

# unmedicated:       # Bradley-trained:  

Were there any unusual circumstances of previous births?
 

Have you had any problems with this pregnancy?
 

What method do you plan to pay your $50 deposit?

        Paypal
        Check or money order in the mail
        Already sent payment
        Other (please specify):

(You will be able to view payment instructions on the next page.)