CHILDBIRTH PREPARATION REFRESHER (Weeknight)

$20.00 *

$ 20.00 Weeknight Refresher

Email Address
*

Childbirth and Beyond

First Name
*

Last Name
*

Address
*

City
*

State
*

Zip Code
*

Phone (Home)
*

Phone (Work)

Name of person attending class with you
*

Please type in your due date
*

(clear)

Which pregnancy is this for you
*

Please type in your doctor’s name
*

What is your age
*

Credit Card Information

Card Type

Card Number

Enter numbers only, no spaces or dashes.

Security Code

Usually the last 3-4 digits in the signature area on the back of the card.

Expiration Date

Billing Name and Address

Enter the name as shown on your credit or debit card, and the billing address for this card.

Billing First Name

Billing Middle Name

Billing Last Name

Street Address

City

Country

State / Province

Postal Code

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