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Civista Health Mail-In • Fax-In Class Registration Form

This form is provided for printing and mailing only. Do not e-mail this form. Pre-registration and prepayment (if applicable) are required at least three business days in advance for all classes. Registrants will receive class confirmation via US mail and will be contacted via phone if the class limit has been exceeded or if the class is unavailable. Make Checks Payable to Civista Health
Civista Health • Community Education • P.O. Box 1070 • La Plata, MD • 20646 • Fax 301.609.4470

 

Class: ...............................................................................................................................................................

Date: .................................................................................

Registration Fee: $ ...............................................................
If you are signing up for one of the following classes please supply additional information:

• Sibling Class or Sign for Baby Class

Child's Name: .........................................................................................................................

Birth Date: .........................................................

• Childbirth Class, Baby Care or Breastfeeding Class

Estimated Due Date: ............................................

Partner/Support Person'sName: .......................................................................................

Name: .............................................................................................................................................................

Address: .........................................................................................................................................................

City, State, Zip: ...............................................................................................................................................

Work and Home Phone Numbers: ...................................................................................................................................

Check or Money Order Enclosed; Amount: $.......................................................

Visa, Mastercard, Discover (circle one)

Cardholder Name (as appears on card): ...........................................................................................................

Account Number: ..... ..... ..... ..... -..... ..... ..... .....-..... ..... ..... ..... -..... ..... ..... .....

Expiration Date: .........................

Cardholder Signature: ...........................................................................................