Childbirth Class Registration Form

Title: Childbirth Education: 4-Session Series (July 8, 15, 22, 29) Start Date:
7/8/2013 
Location: Womens Medical Center
Medical Arts Building
1201 South Drive, Suite 220
Mt. Pleasant, MI 48858 Cost: There is a $60 fee for this program. [*Class costs may be covered for Medicaid participants.]

*Indicates required information

Personal Information

Number Attending:*



Expectant Mother Name:*

Expectant Mother Date of Birth (mm/dd/yyyy):*

Street Address*

City/State/Zip*

Email*

Phone*

Name of OB/GYN Physician:*

Expected Date of Delivery:*
Due to limited class size and availability,
new moms planning on delivering at MCM will
receive top priority for class participation.

Support Person Name:

Payment information will be sent to you via email when your registration is received.