Fill out the form with your keyboard, print it and then mail it with a check.

CHILDBIRTH EDUCATION ASSOCIATION · PO BOX 58573, CINCINNATI, OHIO 45258-0573
Mother's Name Birthing Partner's Name
 Address City State Zip
Home Phone Work Phone Mother's Age Due Date
Dr's Name Hospital to be delivered # of previous pregnancies
 
 It is necessary to register separately for each class

Basic  5 Week Class - Location, starting date and time you plan to attend:
 
Basic All Day Class -  Location, starting date and time you plan to attend:  

 Breastfeeding - Location, starting date and time you plan to attend:           

 Cesarean Section - Location, starting date and time you plan to attend:     

 Refresher - Location, starting date and time you plan to attend:                  
 

Mark your calendar.  There is no phone or mail confirmation! 

Special circumstances regarding pregnancy


I heard about these classes through Doctor Advertisement Friend Other ____________________________
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.

For Instructors use only 1  2  3  4  5  6   Fee ___________  Date Paid _________

 

HOMEPAGE