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

*
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
Breastfeeding and returning to work $55 fee due

Please enter date you plan to attend.

Labor and Delivery Express $55

Please enter date you plan to attend.

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 - Only if BED REST or lives out of service area. Insurance covers fee

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.

Fill in health insurance information if paying by insurance

Health Insurance Company
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.