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Required fields are marked with asterisks (*)

Online prenatal program registration

E-mail address (your online prenatal education access code will be sent to this address)

Phone number

Parent's first name

Parent's last name

Parent's date of birth

Estimated due date

Partner or support person information (optional)

Support person's name

E-mail (this e-mail address will also receive a link to the online prenatal program)

By checking this box, I acknowledge I have read, understand, and agree the information provided in this form is correct

Yes

I would like to receive email communication from KFL&A Public Health

Yes

Personal information on this form is collected under the authority of the Health Protection and Promotion Act, and in accordance with PHIPA and will be used for assessment, management, treatment and reporting purposes. Questions about the collection should be addressed to the program director Kelly Monaghan, at 613-549-1232, ext. 1254