Childbirth Education Registration Form

All classes are held at Whidbey General Hospital
Lower Level - Conference Rooms A & B
4 Week Class 7:00pm - 9:30pm. Saturday class 9:00am - 1:00pm

Please be sure to fill in your mailing address and phone number so we can contact you both by phone and mail.

First Name: *

Last Name: *

Mailing Address: *

City: *

Zip Code: *

Home Phone: *

Work Phone:

E-Mail: *

Due Date:

Select One:

Four Week Class

One Day Saturday Class

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

Class Dates:

September 7-September 28

October 2

November 2-November 23

December 4

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