Instructions:
Please complete the form below and press the Submit button.
Pregnant Woman's Name
*
Partner's Name
Due date
*
Your email address
Phone 1
Phone 2
Phone 3
Class(es) you have signed up for and are requesting a discount
*
Please select the entry which best represents your financial situation and ability to pay:
*
Select one
We would like to pay the full fee but need to make a payment plan to do so
We have limited income and can afford $200
We have limited income and can afford $150
We have limited income and can afford $100
I don't have any reliable income and would not otherwise be able to attend these classes $50
I am attending a one-time class and can afford $25
Please email me to discuss other options
Security Code
*