Childbirth Class Registration Form

*Indicates required information

Personal Information

Number Attending:*

Expectant Mother Name:*

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

Street Address*




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

Payment Type*

Card number or Medicaid number:*
NOTE: Medicaid does NOT cover Baby Basics
or Breastfeeding Education classes.

The following 4 questions must be answered for credit card payments.

Name as it appears on the card:
Exp. Date:
Security Code (3-digit for Visa, Mastercard & Discover, 4 digit for American Express):
Typing your name here indicates that all of the above information is accurate and acts as your electronic signature
Street Address of cardholder:*

City/State/Zip of cardholder:*

Email of cardholder*

Phone of cardholder:*

Additional Information: