Maternity Classes Registration Form
Phelps Memorial Hospital Center, Family Centered Teaching Program
FIRST, call (914) 366-3359 to confirm class dates and availability and to pre-register.
THEN, please print out, complete, and return this form with a check payable to
"Family Centered Teaching Programs" to:
Phelps Memorial Hospital Center
Attention: Barbara Bruno, RN, Nursing Director, Maternal Child Health
701 North Broadway
Sleepy Hollow, NY 10591
| Names: | ____________________________________ |
| Address: | ____________________________________ ____________________________________ |
| Work Phone: | ____________________________________ |
| Home Phone: | ____________________________________ |
| Email: | ____________________________________ |
| Due Date: | ____________________________________ |
| Name of Class: | Date: | Amount: |
| _________________________ | _________________________ | ___________ |
| _________________________ | _________________________ | ___________ |
| _________________________ | _________________________ | ___________ |
| _________________________ | _________________________ | ___________ |
| _________________________ | _________________________ | ___________ |
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| Total: | ___________ |