Full Name:____________________________________________________________________________

Name you would like us to call you (nametag):_________________________________________

DT Location & Date:_______________________________________________________________

Address:_________________________________________________________________________

City:______________________________________________________________________________

State/Province:_______________ Zip/Postal Code:__________________

Phone:__________________________________________________________

Email:___________________________________________________________

Number of births attended:_______________________________________

Certifications/Experience:__________________________________________________________

___________________________________________________________________________________

Lunches and snacks are included. Please check if you need a vegetarian lunch. _______

If it is the weekend intensive schedule, there is an optional dinner with the instructors on

Saturday night.  Do you think you might like to attend? _______Yes    _______No