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 517.887.7000.

PARENTAL INFORMATION

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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

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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
One-Day Prenatal Seminar Insurance covers fee

Please enter date you plan to attend.

Labor & Delivery Insurance covers fee

Please enter date you plan to attend.

eClass - Insurance covers fee if on bed rest or if you live outside of the service area

Please enter date you plan to attend.

The Best Newborn Care Class ever Insurance covers fee

Please enter date you plan to attend.

Breastfeeding Insurance covers fee

Please enter date you plan to attend.

Infant Safety Insurance covers fee
*
Insurance

Currently we only accept 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.