Footsteps Class Registration Form
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Footsteps Class

 

To register for the Footsteps "Pregnancy to Birth" childbirth education class, please complete the following on-line form.  Once you complete the form and click on the Submit button, the form contents will be transmitted directly to Tracy Shaw, BSN, RN, in Dr. Dullye's office. 

Important: Registrants using the online registration form must also mail a check to: Tracy Shaw, 8160 Walnut Hill Lane, Suite 219, Dallas, TX 75231.

Alternatively, you may complete the form, print it out, and mail or deliver it to Ms. Shaw along with the $100.00 registration fee.

First name:

Last name:

Address:

City:    State:    Zip Code:

Home phone:

Work phone:

Email address:

Coach's first name:

Coach's last name:

Due date (dd/mm/year):

Doctor's name:

Have you had any problems with this pregnancy? Yes     No

    If yes, briefly describe:

 

Last modified: April 01, 2011