Class Registration Form

Expectant Mother First Name:	*
Expectant Mother Last Name:	*
First Name of Partner:	*
Last Name of Partner:	*
Please use phone numbers and e-mail that will be applicable around the time of the baby’s birth (i.e. not work if you’ll be on maternity leave)
E-mail Address:	*
Secondary E-mail Address:
Main Phone:	*
Alternate Phone:	*
Street Address 1:	*
Street Address 2:
City:	*
State:	ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNJNHNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVIVAWAVWWIWY *
Zip Code:	*
Estimated Due Date:	(mm/dd/yyyy) *
Physician Name:	First: Last: *
Hospital Name:	* (Name of Hospital where you’ll be giving birth)
If you are interested in the Refresher Class, please provide the following information:
Ages of Previous Children:
Previous C-Section?	Yes No
Previous Class Taken?	Yes No
If so, what type of class?
Any significant positive or negative events from your previous birth experiences?
Class Registering For: First Timers TUES 8/24/2010 - 10/5/2010 Mosely-Salvatori Conf Ctr Location First Timers SATURDAYS 9/18/2010 & 9/25/2010 Alt PASADENA Location First Timers THURS 9/30/2010 - 11/11/2010 PASADENA Location First Timers TUES 10/19/2010 - 11/30/2010 Mosely-Salvatori Conf Ctr Location First Timers SATURDAYS 12/4/2010 & 12/11/2010 PASADENA Location Private Class
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Upon completion of this registration, an email confirmation will be sent to the address you provided above. This confirmation will include important information regarding the first night of class, so please print a copy for your records. Thank you for registering. I look forward to meeting you in person!