| |
FAMILY
AND COMMUNITY EDUCATIONAL SERVICES| |
|
|
Name - First Last
(underline) |
||
Age |
| Address,
City, St Zip |
|
| Phone:
Day |
|
| Phone:
Evening |
|
| Are
you a member of Kaiser? (not required to enroll) |
No Yes |
| Email |
|
| Please
register me/us for the following: |
class_____________ location____________________ |
| Starting
date: |
|
| How
did you hear about this class? |
Doctor/Nurse
Phone Message Flier Newspaper Friend Other _____ |
| Are
you required to attend a parenting class? |
No Yes By whom?___________ |
| Use
the back of this form to list a specific topic(s) you want to discuss
in this class. |
See comments on back of form. |
|
Use the back of this form to include any information that you feel
might be useful to the instructor for the purpose of this class. |
See comments on back of form. |
A letter/email will be returned to you confirming your reservation.