REACH FOR THE MOON

Antenatal Workshop by Rigel Doula & Ti Moon

Registration form

The following information is required in order to best prepare your workshop, taking into consideration your individual needs. All this information is kept confidential and secure, and will not be shared with third parties. We ❤ privacy and care about yours.

First name and Last name

First Name

Last Name

Date of birth

(DD/MM/YYYY)

Country

Phone

(Please indicate the country code)

Do you wish to receive a text reminder 30 minutes before the workshop?

Due Date

(DD/MM/YYYY)

1st baby/ 2nd/ 3rd/ 4th/or more?

Do you have a birth plan?

(If yes, please kindly send us a copy or write down the big lines below)

Do you have a medical condition?

(Predating or resulting from the pregnancy)

Do you have pains and other pregnancy-related symptoms that cause you discomfort?

(for e.g. sciatica, hemorrhoids, etc.)

Is there anything else I should know and that you'd like to share about you and/or your pregnancy?

First name and Last name of the partner accompanying you to the workshop

First Name

Last Name

Emergency contact

First Name

Last Name

Emergency contact phone number

(Merci de bien vouloir préciser l'indicatif du pays)

Signature

Date

(DD/MM/YYYY)

REACH FOR THE MOON

Antenatal Workshop by Rigel Doula & Ti Moon

Registration form

ti moon