Warranty Registration Form

If you are a professional in the medical, educational or social service fields, call Birthways at (800) 882-3559
birthways@empathy belly.org

Birthways Childbirth Resouce Center, Inc.

Please fill out and submit the warranty registration form below for quick online registration. You can also print and mail/fax the PDF version.

"THE EMPATHY BELLY"® PREGNANCY SIMULATOR
WARRANTY REGISTRATION FORM

Name:

Name of Organization:

Complete Mailing Address:

Work Phone:

Date of Purchase:

Email Address:

Occupation/Profession:

Number of years in Profession:

Gender:

Female Male

For what purpose(s) will you be using The Empathy Belly? (check all that apply)

Teen Pregnancy Prevention
Prenatal Education
Domestic Violence Prevention
Museum Exhibit
TV Show, Movie or Theatre

Life Skills Education
Medical Training
College Education
Private Counseling
Actor's Training

From whom did you purchase your Empathy Belly(s):

Birthways, Inc.
Nasco
Health Edco
Childbirth Graphics
Sax School Specialty
Directional Learning

Denoyer-Geppert
Japan Family Planning Assoc.
The Health Connection
Camera Mundi
Other:

Where have you seen ads about The Empathy Belly in any of the following?
(check all that apply)

Nasco Catalog
Health Edco Catalog
Childbirth Graphics Catalog
Sax School Specialty Catalog
Directional Learning Catalog
Denoyer-Geppert Catalog
A.A.F.C.S. Journal
F.C.C.L.A. Publication "Advisor"

A.S.P.O. Publication "Genesis"
I.C.E.A. Journal
Healthy Teen Network Publication
What's New in Home Economics Magazine
Birthway's Website of The Empathy Belly
Other:

What are the most important reasons influencing your purchase of The Empathy Belly? (check all that apply)

The Product's Reputation
Previous Experience or "tried it on"
Features (i.e. Symptoms Simulated)
Hands-on Teaching Tool
Teacher Training Materials Included
Repeat Purchaser of the Product
Quality & Durability

Conference or Workshop Exhibit
Received a Grant to Purchase
B.E.T.A. Trust Fund Assistance
Word of Mouth Recommendations
TV, Radio or Newspaper Publicity
Free, Promotional Videotape of Product

What would make it possible for you to buy more Empathy Bellies that you want?

If you have any questions or comments about this warranty registration, or about your Empathy Belly, please feel free to contact us at Birthways at (800) 882-3559 or email us at birthways@empathybelly.org

NOTE: ALL INFORMATION IS FOR WARRANTY/INTERNAL USE ONLY AND WILL NOT BE SOLD OR RENTED AS PART OF ANY MAILING LIST