EPO Online Registration Form

Our online Registration Form is for customers paying with a credit card or insurance (PHP or SPHN).

If you wish to pay by check, please download the Registration Form (PDF document) and mail in with your check. You can also pay by credit card or insurance with the downloadable registration form.

If you have any questions, please contact the EPO office at 517.337.7365.
  

PARENTAL INFORMATION

*
Woman's First Name
*
Woman's Last Name
*
Woman's Race

African American, Asian, Caucasian (White), Hispanic, Multi or Bi-Racial, Native American, or Other

*
Marital Status

Single, Separated/Divorced, Married, Widowed

Age
Partner's Name
Partner's Race

African American, Asian, Caucasion (White), Hispanic, Multi or Bi-Racial, Native American, Other

Partner's Age

CONTACT INFORMATION

*
Address
*
City
*
County
*
State
*
Zip Code
*
Home Telephone

Format: (xxx) xxx-xxxx

Work Telephone

Format: (xxx) xxx-xxxx

Email Address

DEMOGRAPHIC INFORMATION

*
Combined Family Income

$0 - $24,000
$24,001 - $33,000
$33,001 - $42,000
$42,001 - $51,000
$51,001 or above

*
Due Date

Format: mm/dd/yyyy

First Baby

Yes or No

Physician/Midwife Name
*
Hospital of Delivery
*
Woman's Education
Woman's Occupation
Partner's Education
Partner's Occupation
Health Insurance Company

EPO PRENATAL PROGRAMS

ENTER DESIRED CLASS DATE OR SERIES START DATE FROM THOSE LISTED UNDER THE CLASS DESCRIPTION.

Prenatal Series (Evenings) $119
Prenatal Series (Saturday morning) $119
One-Day Prenatal Seminar $144
The Best Newborn Care Class Ever $110
Newborn Care and Feeding Class Only $44
Breastfeeding Class $44
Labor & Delivery Refresher $80
eClass Program $60
Other Class:
I wish to pay by:

Insurance or Credit Card

Insurance

PHP or SPHN (Sparrow Associates Only)

Group Number
Subscriber Number
Card Holder's Birth Date
I would like to make the following donation to the EPO Scholarship Fund.
PAYMENT INFORMATION
*
Amount:
*
Card Type:
select
*
First Name:
*
Last Name:
*
Billing Address:
Billing Address Line 2:  
*
Billing City:
*
Billing State:
*
Billing Zip:
*
Expiration:
select
/
select
*
CVC:
*
Card Number:

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