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Mother's Name
Birthing Partners Name
Address
City State Zip
Home Phone
Work Phone
Mother's Age
Due Date
Doctor's Name
Hospital to be Delivered
# of Previous Pregnancies
Special Circumstances
Where did you hear about these classes?
Location, starting date and time you plan to attend
Mark your calendar. There is no phone or mail confirmation

List all the classes you plan to attend
Basic 5 week class
Basic All Day
Breastfeeding
Cesarean Section
Refresher Class

No Refunds. Transfer requests granted only when received 1 week prior to start of the original class and availability permits.
A $10 handling fee will be charged.
Instructors use only 1 2 3 4 5 6 Fee _______ Date Paid __________