Group Class Registration
Contact Information
Name
*
Birth Partner Name
Estimated Due Date
*
Planned Place of Birth
Address
*
City
,
State
and
ZIP Code
*
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AA
AE
AP
Phone Number
*
Email Address
*
Food Allergies?
Classes & Additional Services
Thoughtful Childbirth
*
Wednesday Series: 1/29-2/19 from 6-9pm ($225.00)
Would you like to add other services?
Prenatal Consultations ($200.00)
Virtual Birth Doula Support ($225.00)
Total
$0.00
Terms & Agreements
Terms & Agreements
*
In the event of illness on the part of the instructor, a birth, or inclement weather, class may be rescheduled.
By completing this online registration form, you are agreeing to pay the total amount due for the services selected above. Once payment is received, no refunds will be issued and all sales are final.
We require a minimum of 4 couples per group class. If we do not meet that minimum, class may be rescheduled. If a class must be cancelled, your payment will act as a credit toward a private class or will be refunded in full.
For questions, please contact Bloom Birth Concierge at (412) 330-1159 or Hello@BloomBirthConcierge.com.
I have read and agree to the terms above.
Billing Information
Name
*
Card Number
*
Visa
Mastercard
American Express
Discover
Expiration Date
*
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Address
*
City
,
State
and
ZIP Code
*
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AA
AE
AP
Email
*
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