TriangleChildbirth - Registration

Registration Form

Name : Due Date:

Address: List any days you can't attend:

City/State/Zip: Hospital/Birth Center Info:

Home/Work Phone: Email:

Who should I thank for your referral?

Do you have any fears about this birth?

Print and send this form with your $25.00 registration fee to: Carol Horrocks

(Your registration fee will be applied towards the class fee. ) 12212 Glenlivet Way

Raleigh, NC 27613

I will contact you with class information, directions and availability.

Thank You

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Name :	Due Date:
Address:	List any days you can't attend:
City/State/Zip:	Hospital/Birth Center Info:
Home/Work Phone:	Email:
Who should I thank for your referral?

Print and send this form with your $25.00 registration fee to:	Carol Horrocks
(Your registration fee will be applied towards the class fee. )	12212 Glenlivet Way
	Raleigh, NC 27613