HEY Baby Course Booking Form 1Screening Questions2Personal Details3Course Preferences Unique IDAre you registered with a Hull GP?* Yes No You can choose to book onto the optional Week 4 session which covers breastfeeding awareness, but the HEY Baby courses Weeks 1-3 are unfortunately available only to those registered with a Hull GP. If you are registered with an East Riding GP, you can contact your local Sure Start Children's Centre.Have you had your 20-week scan? Yes No Please return to complete the online booking form following your 20-week scan.Would you like to book onto the Weeks 1-3 antenatal classes?* Yes No Would you like to book onto the Week 4 optional breastfeeding awareness session?* Yes No Your Title* Mrs Miss Ms Your Name* Forename Surname Your Date of Birth*DDDD12345678910111213141516171819202122232425262728293031MMMM123456789101112YYYYYYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Hospital Number*This can be found on the front of your maternity records.What is your expected due date?*DDDD12345678910111213141516171819202122232425262728293031MMMM123456789101112YYYYYYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Address* Address Line 1 Address Line 2 Town / City Postcode Your Telephone Number*Your Email Address* Enter Email Confirm Email What is your preferred method of contact?* Telephone Email What is your ethnic origin?Please select (optional)White: BritishWhite: IrishWhite: OtherMixed: White and Black CaribbeanMixed: White and Black AfricanMixed: White and AsianMixed: OtherAsian: IndianAsian: PakistaniAsian: BangladeshiAsian: OtherBlack: CaribbeanBlack: AfricanBlack: OtherChineseOther Ethnic GroupIs this your first baby?* Yes No Please provide any significant details about this and any previous pregnancies. Will someone be attending the course with you?* Yes No What is the name of the person attending with you?* Forename Surname What is this person's relationship to you?*Please choose one:* I acknowledge that I will be receiving my Antenatal education via an online group platform I do not have access to the internet and would prefer my Antenatal education via an alternative method This field is hidden when viewing the formWhich of the following options would you prefer when booking onto your Week 1-3 antenatal classes?Please select one or more preferences. East Hull – 3 weeks - Marfleet Childrens Centre, Preston Road, Hull, HU9 5HH - Monday Evenings North Hull – 3 weeks - Lemon Tree Childrens Centre, Lothian Way, Hull, HU7 5DD - Tuesday Evenings West Hull – 3 weeks - Priory Childrens Centre, Priory Road, Hull, HU5 5RU - Wednesday Evenings Central Hull – 3 weeks - Women & Childrens Hospital, Anlaby Road, Hull, HU3 2JZ - Thursday Evenings Twins/Multiples - 2 weeks only – Women & Childrens Hospital, Anlaby Road, Hull, HU3 2JZ – Monday Evenings Please note that the Week 4 breastfeeding awareness session is held once a month at Hull and East Yorkshire Women and Children's Hospital.Special RequirementsPlease use this box to tell us about anything specific to do with your pregnancy and/or your personal needs, including any disability.How did you hear about HEY Baby antenatal classes?* Midwife HEY Baby Carousel event Social Media Friend / Family
