Clarksdale Baby University Registration Form

Clarksdale Baby University Parenting Classes

Fill out the registration form carefully.
Are you a returning participant or new participant?

NewReturning
Participant Name

First NameMiddle NameLast Name
Which class will you attend?*

Winter Session: Jan. 27 - Mar. 17, 2025 (Graduation March 20th)Spring Session: April 7 - May 27, 2025 (Graduation June 5th)Summer Session: July 21 - Sept. 8, 2025 (Graduation September 11th)Fall Session: Oct. 27 - Dec. 15, 2025 (Graduation December 18th)
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Mobile Number
Phone Number
Name of person who can always contact you:

First NameLast Name
Phone number of the person who can always contact you:
Are currently pregnant?

YesNo
If yes, what is your due date?

MonthDayYear
Date
Please list children's names, ages, and birthday of all children:
Do you have internet access?

YesNo
Do you need assistance with transportation to the in-person sessions?

YesNo
Should be Empty:

Clarksdale Baby University Parenting Classes