Registration form for ICEA Professional 
Childbirth Educator Workshop

 Please print this page and fill out legibly, 
mail in with your fee

 Name:________________________________________________

Degrees:_______________________ 

Date of Workshop you are attending:______________________________

 Street Address:_______________________________________________________________

 City:_____________________ 
 State:___________________
 Zip Code: ___________

 Phone:______________________________   
 Alternate: ___________________
 Email: ________________________________________


FEE AMOUNT PAID:_____________________________________   
Food allergies or unable to eat___________________________________________
Are you interested in ICEA certification:____________
Are your hours for Nursing CEU's ______________________________________________
 ALL INFORMATION STATED ABOVE IS CONFIDENTAL
Contact Infornation:

Kathy King
16042 Hi Land Cir.
Brighton, CO 80602

Home: 303-655-9095

Cell: 303-916-1978

Email:proed448@gmail.com