Meditation for Prenatal Health Registration Form

CALM BIRTH WORKSHOP – Meditation for Managing the Discomfort of Pregnancy & Childbirth

Instructor: Deborah Jordan 530-271-7390/913-5899 For births in home or hospital

Location: Wild Mountain Yoga Center, 574 Searls Ave., Nevada City, CA 95959 530-265-4072

Saturday, October 7, 2006 2:00 – 5:00 pm

START YOUR PRACTTICE AS EARLY AS POSSIBLE TO ENHANCE YOUR CHILDBIRTH EXPERIENCE FOR YOU AND YOUR BABY

$35 per woman/$65 per couple Discount if register by Sept. 13

$35 Materials Fee: Book & guided meditation CD

HELPFUL HINTS:

Please arrive on time. Dress in comfortable clothing.

Bring your own mat or rent one from the studio for $1 each class.
Feel free to use the bathroom and get water (in the lobby) whenever you need.
For maximum benefit, let instructor know if you are uncomfortable.

________________________________________cut here________________________________________________

CALM BIRTH Meditation for Pregnancy/ Childbirth –submit check to D. Jordan and this completed form :

Deborah Jordan, P O Box 773, Grass Valley, CA 95945 or drop off at Wild Mountain Yoga Center

Saturday Workshop 2-5 pm                    For more information call (530) 271-7390 or 913-5899

Your                                                                                           Partner’s                                                   Due Date:___________

Name :_______________________________     Name :___________________

Address: ____________________________          Address: _____________________________________

Phone:     ____________________________           Phone: ______________________________________

Cell: ______________________________          Cell: _______________________________________

Email: _____________________________           Email: _____________________________________

Have you done meditation?___ If yes, what style? _________Has partner?____ If yes, what style? _____________

Have you given birth to other children?_____What sex & age(s)?_____________________________________

List any injuries or physical conditions that interfer with breathing or sitting? _______________________________

Partner, injuries or physical conditions?______________________________________________________

Please circle your interest: Homebirth/Midwife, Doctor/ Hospital, Doula? Name of provider(s): ____________________

Practicing meditation is about practicing self-care and self-responsibility. I understand that I am completely responsible for my experience: during class, during childbirth; and release the instructor, Deborah Jordan and Wild Mountain Yoga Center from any and all liability.

$35 per woman/$65 per couple Discount if register by Sept. 13

$35 Materials Fee: Book & guided meditation CD

Your Partner’s Due Date:___________

Name :_____________ Name :_

Email: _ Email: _________

Have you done meditation?_ If yes, what style? _Has partner? If yes, what style? _______

List any injuries or physical conditions that interfer with breathing or sitting? _______________________________

Partner, injuries or physical conditions?______________________________________________________

Please circle your interest: Homebirth/Midwife, Doctor/ Hospital, Doula? Name of provider(s): ____________________

Practicing meditation is about practicing self-care and self-responsibility. I understand that I am completely responsible for my experience: during class, during childbirth; and release the instructor, Deborah Jordan and Wild Mountain Yoga Center from any and all liability.

Pregnant Partner:_____________________ Date:

Partner:_____________________________ Date:

I grant my permission for my phone number to be shared with the group: YES NO CALMBIRTHREGFORM: Sept.2006

$35 per woman/$65 per couple Discount if register by Sept. 13

$35 Materials Fee: Book & guided meditation CD

Your Partner’s Due Date:___________

Name :_______________________________ Name :___________________

Email: _____________________________ Email: _____________________________________

Have you done meditation?___ If yes, what style? _________Has partner?____ If yes, what style? _____________

List any injuries or physical conditions that interfer with breathing or sitting? _______________________________

Partner, injuries or physical conditions?______________________________________________________

Please circle your interest: Homebirth/Midwife, Doctor/ Hospital, Doula? Name of provider(s): ____________________

Practicing meditation is about practicing self-care and self-responsibility. I understand that I am completely responsible for my experience: during class, during childbirth; and release the instructor, Deborah Jordan and Wild Mountain Yoga Center from any and all liability.

Pregnant Partner:_______________________________________ Date:__________________

Partner:_______________________________________________ Date:__________________

I grant my permission for my phone number to be shared with the group: YES NO CALMBIRTHREGFORM: Sept.2006

Name :_____________ Name :_

Email: _ Email: _________

Have you done meditation?_ If yes, what style? _Has partner? If yes, what style? _______

Pregnant Partner:_____________________ Date:

Partner:_____________________________ Date: