Course Registration Form - Choose Life A&V

CHOOSE LIFE A&V

International Program Department, Vancouver, Canada

COURSE REGISTRATION FORM

Completed after the applicant has received written approval from her treating physician. This form registers the applicant for the selected course. Arrival preparation is handled in a separate form.

SECTION 1: REGISTERED APPLICANT

First Name (as in passport): _________________________________________
Family Name / Surname (as in passport): _________________________________________
Date of Birth (DD/MM/YYYY): ____ / ____ / ___________
Citizenship: _________________________________________
Country of origin: _________________________________________
Passport Number: _________________________________________
Country / City of Residence: _________________________________________
Email: _________________________________________
Contact Number (WhatsApp/Telegram): _________________________________________
Language of communication: _________________________________________
Application reference / Order number: _________________________________________

Is the applicant a Canadian citizen or permanent resident? [ ] Yes [ ] No

SECTION 2: MEDICAL APPROVAL (TWO STAGES)

Stage 1 — approval from your own treating physician.

The attending physician has confirmed, in writing, that the applicant is medically able to carry a pregnancy and give birth:

[ ] YES, approval received. Date of physician approval: ____ / ____ / ___________
[ ] YES, with conditions (please specify): ______________________________________
[ ] NO / pending

The attending physician has also confirmed that the physical exercises of the course are not contraindicated for the applicant:

[ ] YES, exercises are permitted
[ ] YES, with limitations (please specify): ______________________________________
[ ] NO / pending

Approving physician: _________________________________________
Medical License / Registration Number: ___________________________
Clinic / Hospital: _________________________________________
Country / City: _________________________________________

Attached documents:

[ ] Signed and stamped Physician Medical Stability Form
[ ] Diagnostic lab results (last 3–6 months)
[ ] Written physician approval letter

Stage 2 — approval from the Choose Life A&V doctor.

After your documents are received, our doctor reviews them and issues a separate clearance confirming that the course and its exercises are safe for you. The course cannot begin until this second approval is granted.

[ ] I understand that participation also requires written clearance from the Choose Life A&V doctor.

For internal use — Choose Life A&V doctor clearance: [ ] Granted [ ] Granted with limitations [ ] Not granted
Date: ____ / ____ / ___________ Reviewing doctor: _______________________

SECTION 3: CONDITIONS REQUIRING ONGOING STABILITY SUPPORT

Chronic conditions to be monitored during the course:

[ ] Diabetes (Type 1 or 2)
[ ] Bronchial Asthma
[ ] Cardiac Disease
[ ] Epilepsy / Seizures
[ ] Severe or anaphylactic allergies
[ ] None

Other conditions (please specify):
____________________________________________________________________________

Ongoing medication protocol to be maintained:
____________________________________________________________________________
____________________________________________________________________________

Specialist supervision required during the course (e.g. endocrinologist, cardiologist):
____________________________________________________________________________

SECTION 4: COURSE REGISTRATION & PAYMENT ROUTE

Course the applicant is registered for:

[ ] _________________________________________
[ ] _________________________________________
[ ] _________________________________________

How does the applicant plan to cover the course?

[ ] Full payment for the course, paid personally
[ ] Client Partner Program — full participation
[ ] Client Partner Program — partial participation, the rest paid personally
[ ] Financing / instalments needed
[ ] Not yet decided — would like to discuss the options

If partial — approximate share the applicant will pay personally: [ ______ % ]

Registration fee status: [ ] Paid [ ] Pending
Assigned Choose Life A&V coordinator: _________________________________________

Plan of stay

After completing the program, if pregnancy is confirmed, please indicate your current plans regarding your stay in Canada:

☐ I plan to return home after the 14-day program.
☐ I may return to Canada later if pregnancy is confirmed and I decide to give birth in Canada.
☐ If pregnancy is confirmed, I may consider staying in Canada until delivery.
☐ If pregnancy is confirmed, I may consider staying in Canada before and after delivery.
☐ I have not decided yet.

This question is for planning purposes only and does not guarantee pregnancy, medical care, visa approval, an extension of stay or delivery in Canada.

If staying for the birth — expected due date (DD/MM/YYYY): ____ / ____ / ___________

What the course includes

Medical supervision by the attending doctor
Clinical recommendations and a personal stability protocol
Online consultations and meetings with specialists
Home birth
Assistance with the Canadian entry visa process, including invitation and support letters
Continuing adaptation support in Vancouver: you may come to us with any question, and we help you find a house or apartment to rent and a car to rent

What the course does not include

Rent and accommodation costs, during the course and for any period before or after the birth
Car rental costs
Government visa fees
Hospital delivery, if it becomes medically necessary
Flights, transfers and daily living costs

Please note: the course includes home birth only. Rent must be arranged in advance of arrival and is paid by the applicant; we help you find it.

[ ] I understand that the course covers home birth only.
[ ] I understand that rent and accommodation are not included and must be arranged in advance.

Doula

Would you like a doula to accompany the birth?

[ ] Yes, please arrange a doula
[ ] No, not required
[ ] I would like more information first

Preferred language of the doula: _________________________________________

SECTION 5: ENTRY VISA

We guide you through the Canadian entry visa process and prepare the supporting documents from our side.

Does the applicant need an entry visa to come to Canada?

[ ] Yes, a visa is needed
[ ] No, eTA only (visa-exempt passport)
[ ] No, already holds a valid Canadian visa or permit
[ ] Not applicable — Canadian citizen or permanent resident
[ ] Not yet determined — please advise me

How many people in total will need a visa, including accompanying family? [ ______ ]

Please list everyone who needs a visa:

1. First Name: ____________________ Family Name: ____________________
Relationship (husband, mother, other): ____________________
Country of origin: ____________________ Citizenship: ____________________

2. First Name: ____________________ Family Name: ____________________
Relationship (husband, mother, other): ____________________
Country of origin: ____________________ Citizenship: ____________________

3. First Name: ____________________ Family Name: ____________________
Relationship (husband, mother, other): ____________________
Country of origin: ____________________ Citizenship: ____________________

Help you would like from us:

[ ] Invitation / support letter for the visa application
[ ] Guidance on which documents to prepare
[ ] Help completing the application
[ ] None, we will handle it ourselves

Full travel and visa details are collected later, in the arrival preparation form.

SECTION 6: MEDICAL INSURANCE

Do you already have medical insurance valid in Canada?

[ ] Yes, Canadian provincial health coverage (e.g. BC MSP)
[ ] Yes, a private or premium Canadian medical insurance plan
[ ] Yes, travel medical insurance included with my platinum or gold credit card
[ ] Yes, another policy (please specify): ____________________________________
[ ] No coverage yet

Insurance provider: ____________________________ Policy number: ____________________________
Coverage valid until (DD/MM/YYYY): ____ / ____ / ___________
Does the policy cover pregnancy and childbirth? [ ] Yes [ ] No [ ] Not sure, please check for me

Would you like Choose Life A&V to arrange medical insurance for the period of your stay in Canada?

[ ] Yes, please arrange medical insurance for me
[ ] Yes, also for my accompanying family members
[ ] No, my existing coverage is sufficient
[ ] I would like more information first

[ ] I authorise Choose Life A&V to arrange and purchase medical insurance on my behalf.
[ ] I consent to Choose Life A&V using and disclosing my medical information to insurance providers solely for the purpose of arranging this coverage.

SECTION 7: APPLICANT CONFIRMATION

[ ] I confirm that the information registered above is accurate and complete.
[ ] I consent to Choose Life A&V registering my case with the receiving licensed Canadian clinic.
[ ] I consent to my treating physician and Choose Life A&V exchanging my medical records and clinical updates throughout the course.
[ ] I understand that if I have pre-existing pathologies, the course includes medical support aimed at keeping my condition stable.

Applicant Signature: _______________________ Date: ____ / ____ / ___________

FOR INTERNAL USE – CHOOSE LIFE A&V

Registration number: _______________________
Date registered: ____ / ____ / ___________
Reviewed by: _______________________ Signature: _______________________