Mother Matters

Mother's Full Name:
Age:
Profession:
Partner's Name
Age:
Profession:
Address:
City:
Prov:
Postal Code:
Home Phone #:
Alternate Phone #:
E-mail:
Phone # for cancellation of classes:
Due Date:
Intended place of birth:
Care giver:
Is this your first pregnancy?	Yes: no:
If no, please state name and age of children. In case of any miscarriages or stillbirths please state dates:
Are you taking any medication? (if yes please state type)
Intended method of feeding your baby:
Type of course:
How did you hear about the classes?
Start date of course:
Location of course:

Burlington and Area Midwives
4332 New Street
Burlington Ontario

Please note that a minimum number of registrations is necessary to go ahead with the classes. Courses can be cancelled up to a week before the scheduled date. In case of cancellation, full refund will be given and private or semi-private classes can be arranged with the instructor for the appropriate fee.