Registration Form

To register for a group breastfeeding class, please print out, complete, and mail this form with your class fee.

Please register me for the group breastfeeding class for the month of ___________ .

Please call (516) 365 4877 or email info@breastfeedingresources.net for upcoming class dates and fee.

Name/s _____________________________________________________

Address __________________________________________Zip________

Phone _________________________Email_________________________

Fax _________________

Due Date____________

Referred by:__________

Note: Fee must accompany registration. If attending as a couple, second registration is free. Please make check payable to Beverley Rae and mail with this form to Breastfeeding Resources, 64 Manhasset Woods Road, Manhasset, NY 11030