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 517.887.7000.

PARENTAL INFORMATION

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

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

*
Marital Status

Single, Separated/Divorced, Married, Widowed

Partner's Name
Partner's Age
Partner's Race

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

CONTACT INFORMATION

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

Format: (xxx) xxx-xxxx

*
Email Address
*
Due Date

Format: mm/dd/yyyy

First Baby

Yes or No

Multiples

*
Woman's Education
Woman's Occupation
*
Combined Family Income

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

Partner's Education
Partner's Occupation
Physician/Midwife Name
*
Hospital of Delivery
Labor and Delivery Express $55

Please enter date you plan to attend.

eClass Program $100

Please enter date you plan to attend.

Best Newborn Care $120

Please enter date you plan to attend.

Private Class (pre approval required) $195

Please enter date you plan to attend.

Labor & Delivery $100

Please enter date you plan to attend.

One-Day Prenatal Seminar $140

Please enter date you plan to attend.

Breastfeeding Class $75

Please enter date you plan to attend.

Infant Safety $75

Please enter date you plan to attend.

Childbirth Comprehensive $215

Please enter date you plan to attend.

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: