Pregnancy Nutrition Development Class Registration
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Birth Date
*
/
Month
/
Day
Year
Date
Due Date
*
-
Month
-
Day
Year
Date
Will anyone be attending class with you? (Everyone is welcome to bring a support person to each class).
*
Yes
No
Name of the person attending & their relationship to you.
We provide childcare during our classes for children 6 and under. Will you need childcare?
*
Yes
No
If yes, for how many children? what are their ages?
Client permission to use photographs/videos taken at BRPC. I give my full permission for BRPC to take photographs or videos of myself or my child and I understand that any written information regarding myself or my child may be used in conjunction with the BRPC marketing and advertising materials. For example, websites, Social Media, and printed material such as newsletters, but not limited to any of these. There will be no time that any affiliation of myself or my child’s name will be mentioned or tagged in any photos by BRPC.*Each picture or video posted and/or used will remain anonymous by BRPC. I give my full permission for the photos to be used by BRPC.
*
Yes
No
Submit
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