EPO Class Registration Form

PHP or SPHN Insurance ONLY

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 (client pays $34)
Teen Prenatal Series $69
Labor & Delivery Refresher $80
Newborn Care and Feeding $44
eClass - Only if mom is on bedrest or out of area. $60
Other Class:
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.

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