Registration for Childbirth Education Classes

 

Name:____________________________________________________________

Address:__________________________________________________________

             __________________________________________________________

Telephone number:_________________________________________________

Your date of birth:____________________________________

Do you work or go to school?____________________________________

Will anyone be attending classes with you?  If so, what is their name and relationship to you?_________________________________________________________________________

What is your estimated date of delivery?___________________________________________

Who is your doctor of midwife?___________________________________________________

Do you have aother children?____________________
Names and ages________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Anything else you'd like me to know about you?  Has your pregnancy been healthy?  Do you have any unusual stresses or circumstances?  Do you have any questions you'd like me to answer before classes start?______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

 

Classes are free, but you must return this registration to serve your space in class.

Cape Cod Children's Place, Inc.
PO Box 1935
10 Forest Ave, (off Nauset Rd.)
North Eastham, MA  02651
508-240-3310  800-871-9535
Charlotte Fyfe, Family Support Consultant