I certify that I am a Childbirth Educator, RN, DONA, midwife or other healthcare professional who is actively involved in directing, coordinating and/or teaching at least 4 courses per year.

* I certify that I will use and/or will encourage others within my organization to use the Family4Life LaborGear Bag and/or brochures I receive for in-class demonstrations, and not for personal use outside of my involvement in childbirth classes and/or labor and delivery.

* I certify that I will fax copies of my organization's birthing/labor & delivery related class schedules and class descriptions while participating in this program.

* I realize that if I decide not to use the Family4Life LaborGear Bag for in-class demonstrations or for labor and delivery related experiences, for whatever reason, I will notify Family4Life.

* I realize that I will be notified within 10 business days via email if approved. If I do not receive an email notification, then I may resubmit my registration within 30 days.

Copies of your class schedules and descriptions are required prior to receiving your LaborGear Bag and/or starter kit.

Fax to: (251) 633-4552









Please complete the information below. You may submit this form online, or print this page and fax this form to us at: (251) 633-4552.


http://family4life.com/cepartners/cepform.htm