Welcome! Please help me get to know your family better by completing the form below. Warmly, Nikki Shaheed Name* First Last Email* Phone*Partner's NamePartner's Email Class Series*2020.10 October 21 - November 112021.01 January 6 - 272021.02 February 4 - 252021.03 March 3 - 242021.04 April 7 - 282021.05 May 5 - 26Payment Amount* $50 $75 $100 $150 $200 On the following page you will be prompted to pay a 25% deposit to reserve your space in class unless your payment amount is $0. The remaining balance can be paid any time between now and the end of our first class. Estimated Due Date:*Where you plan to give birth?*This is my baby #* 1 2 3 or more How did you hear about Birthing from Within classes?What are you most hoping to get out of this class?Is there anything you'd like for me to know about you or your family?CommentsThis field is for validation purposes and should be left unchanged.