The Warrior Exchange Registration Form

Birthing Person *

First Name

Last Name

Pronouns

Select any that apply

she/her

him/him

they/them

prefer not to say

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Partner (If applicable)

First Name

Last Name

Pronouns

Select any that apply

she/her

him/him

they/them

prefer not to say

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Estimated Due Date *

MM

DD

YYYY

Did previous births occur before, on, or after your estimated due date?

Before

On

After

Describe your previous birth experience(s). Check all that apply.

Vaginal Birth

C-section

VBAC

Epidural

Narcotic Pain Relief

Nitrous

General Anesthesia

Unmedicated

Amazing

Satisfying

Traumatic

Scary

Healing

Land Birth

Water Birth

Midwife Attended

OBGYN Attended

Doula Attended

Birth Photographer

I birthed in my intended location

I did not birth in my intended birthing location

My other children were present

My partner was great

My partner was not super helpful

Prodromal Labor

Long Labor

Short Labor

Just Right Labor

Quiet

Loud

Singleton

Multiples

I was induced

I went into labor with some encouragement

I went into labor naturally