Prenatal Program Registration

Please fill out the following information to the best of your ability. We will ensure that any answers you provide are kept strictly confidential. Once you have filled out the form, you will be contacted by Jane Flinders, lead facilitator of the program, to check and confirm enrollment.

Comments
This field is for validation purposes and should be left unchanged.
Name*
First Last
Email*
Enter Email Confirm Email
Phone
Can we text the phone number provided?
- Yes
- No
Please tell us a little about yourself:
Please share any details about previous pregnancies and/or births.
Please share the concerns you have about your wellbeing once you have your baby.
Do you have a history of mental health or wellbeing concerns?
Who would you like to bring as your support person? This is usually a partner, but can also be a family member or close friend.
If you have any dietary restrictions, please describe them here:
Due date for this pregnancy*
MM slash DD slash YYYY
Availability*
I am available to attend prenatal class on Wednesdays from 5:30-7:30 p.m.*
Were you referred to this program? If so, by whom?
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