DFW Births Childbirth Education Registration Form
Full Name
*
First Name
Last Name
Partner's Name (if applicable)
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Class Date
-
Month
-
Day
Year
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First Birth?
Yes
No
Estimated due date
-
Month
-
Day
Year
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Name of OB/Midwife:
Place of Birth:
Please specify which hospital/ birth center. If home, type home.
What do you wish to learn from this class?
Is there anything in particular that you would like information about?
Comments or Additional Information
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Preparing For Birth, Comprehensive
$
550.00
FULL
DEPOSIT
Preparing For Birth MINI
$
350.00
Private Classes Only
FULL
DESPOSIT
Preparing For Your Hospital Birth
$
200.00
Private Classes Only
FULL
HALF
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Total
$
0.00
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