Labor & Birth Class Registration
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Due Date
*
-
Month
-
Day
Year
Date
Requested Class Date & Location
*
Please Select
Saturdays, 1/17 & 1/24, 9:00am-1:00pm - EmPower Health
Thursdays, 1/22 & 1/29, 5:00pm-9:00pm - Online via ZOOM
Thursdays, 2/12 & 2/19, 5:00pm-9:00pm - Online via ZOOM
Saturdays, 2/21 & 2/28, 9:00am-1:00pm - Women’s Health Center Classroom
Place of Delivery
*
Please Select
Queenʻs Medical Center
Undecided
OB/GYNʻs Name
*
First Name
Last Name
Partnerʻs Name
First Name
Last Name
Type of Class
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Labor & Birth Class
If you are a QHS employee, please enter your work email below.
$
80.00
QHS employee?
No
Yes
In-person or virtual
In-person
Virtual
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
QHS Work Email if applicable
example@example.com
Submit
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