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_____________________________
 
 How you want your name on name badge:______________________________________
 
 Street Address:_______________________________________________________________
 
 City:_____________________ State:___________________Zip Code: ___________
 
 Phone:______________________________    Alternate: ___________________
 
 Email: _________________________________________Fax number:__________________
 
 Profession:________________________________________________
 
 Name of Workplace:________________________City:_______________________________
 
FEE AMOUNT PAID:______________________________________________
 
Payment type: ____________________________________________________________
 
 Are you interested in ICEA certification:___________________Recertification_________
 
 Are your hours for Nursing CEU's:_______________________________________________
 
 
Please print out this form, complete and mail in to Kathy with your fee 
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:
proed@q.com