Registration Form

Name_____________________________________________________Occupation___________________

Support Person_____________________________________________Occupation____________________

Address____________________________________________________________

City____________________________________Zip________________________

Home Phone_______________________ Work/Cell______________________

Email Address______________________________________________________

Due Date____________________Doctor______________________Hospital________________________

# of previous pregnancies_____________ Number of children________________ Ages________________

Where did you hear about PCEA?___________________________________________________________

Class selections (Please indicate the code numbers of your selections)

Childbirth series (please pick two choices) #_________ Breastfeeding #__________

#__________ Newborn Care #__________

Please have 2nd choice start date occur after 1st choice start date.

Print this form and mail with Check payable to PCEA to:

PCEA Registrar

7002 Becky Dr.

Canton, Mi 48187