Class Registration

You are registering for:
Childbirth Preparation Class
Location: Family Birth Center 3rd floor
Instructor: Childbirth Instructor
Dates:  Mon September 9, 2013 6:30 PM - 9:00 PM
Mon September 16, 2013 6:30 PM - 9:00 PM
Mon September 23, 2013 6:30 PM - 9:00 PM
Mon September 30, 2013 6:30 PM - 9:00 PM
Mon October 7, 2013 6:30 PM - 9:00 PM
Mon October 14, 2013 6:30 PM - 9:00 PM
Fee: $110

Please give us your contact information:
* First Name:
* Last Name:
* Address:
Address 2:
* City:
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* ZIP Code:
* Phone:
Company:
* Email:
Due Date:
Doctor's Name:
Coach's First Name:
DSHS ProviderOne card: