Instructions:
Please complete the form below and press the Submit button.
Pregnant Woman's Name
*
Partner's Name
Due date
*
Your email address
Phone 1
Phone 2
Phone 3
Class(es) you have signed up for and are requesting a discount
*
Please select the entry which best represents your financial situation and ability to pay:
*
Select one
We would like to pay the full fee but need to make a payment plan to do so
I am experiencing temporary hardship and can afford ____ (minimum $125)*
I am on medical aid and can afford $75
I am attending a one-time class and can afford $25
Please email me to discuss other options
*Please explain circumstances below
Explanation of temporary hardship:
Security Code
*