New Dancing For Birth Class Participant Questionnaire

Please complete this questionnaire before attending your 1st Dancing For Birth class. You will also be required to fill out the Dancing For Birth Class Agreement form prior to participation.

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Name *

First

Last

Email *

Are you currently pregnant? *

• Yes
• No

If you ARE pregnant, how many weeks?

If you ARE NOT pregnant, have you given birth in the past 12 months?

• Yes
• No

If you have favorite music genres, please share.

If you have favorite dance styles, please share.

Photos or videos captured during class belong to Dancing For Birth™ and may be used by your instructor and/or Dancing For Birth™ for commercial or promotional purposes. Do you consent to the use of photography and videography during class? *

• Yes
• No

Any additional information you'd like to share with your instructor?

Submit