Childbirth Education Registration Form

All classes are held at Whidbey General Hospital
Lower Level - Conference Rooms A & B
7:00pm - 9:15pm

First Name: *

Last Name: *

Street Address:

City:

Zip Code:

Home Phone:

Work Phone:

E-Mail: *

Due Date:

Select One::

Full Class

Refresher

We will contact you with the exact classes you will need to attend for the refresher class.

Tuesday Classes:

May 6-27, 2008

July 1-22, 208

September 2-23, 2008

November 4-25, 2008

Do you have any physical impairment that would restrict your involvement in class? (Please explain):

Special Notes:

i.e. 2nd person's name for couple's class

Release

In consideration of participation in this program, I hereby indemnify, hold harmless, and release Whidbey General Hospital, its agents and employees from any and all liability for injury suffered by myself arising from these classes, and I assume all risk for any injuries.

I agree

I disagree

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Childbirth Education Registration Form