Name:_______________________    Date: _____________________

Address: _________________________________________________

City, State, Zip Code:_______________________________________

Phone Number: ____________________  Birth Date:______________

Have you had an unassisted childbirth?  If so, when? ______________
_________________________________________________________

Please describe the birth of your own children on a separate page.

Please state why you want to teach unassisted childbirth. ___________
_________________________________________________________
_________________________________________________________
_________________________________________________________

Do you believe that women's bodies are designed to give birth, and
that most complications are the result of interference in that natural
process? _________________________________________________

Choose a payment option:

_____ $20 application fee, $130 initial downpayment, 3 consecutive
           payments of $200

_____ $20 application fee, $730 payment in full

          $20 application fee, $130 downpayment, 12 payments of $50
 

Please enclose either payment in full, or the $20 application fee.
Payment may be made by personal check, money order, cashiers
check, or PayPal.  If sending the money using PayPal, it will not be
necessary to send money with the application.  If for some reason
your application is rejected, the $20 application fee is non-refundable.

Your signature on this document consistutes a contract which legally
obligates you to complete the payment schedule chosen by you above, in
the event your application is approved.  In the event your application
is rejected, this contract is null and void.

The day I receive your application fee will be the day your payment is
due each month.  Payments later than ten days will be subject to a 10%
late charge.

I understand and agree with the above terms.

_____________________________________
Signature
 

Please make checks payable to Judie C. Rall

Please send completed application and payment to:

Judie C. Rall
157 SW 68th
Lawton, OK 73505

For more information, email at childbirth@unhinderedliving.com

Paypal users send money to childbirth@unhinderedliving.com