2009 Printable Class Registration Form
Send registration form and fee (payable to Regions Hospital)
Cashier's Office, Room 200
Attention: Prenatal Education
Regions Hospital
640 Jackson Street
St. Paul, MN 55101
Mother's Name ___________________________________
Address __________________________________
City _________________________ State ___ Zip Code ________
Home Phone Number ______________________
Work Phone Number ______________________
Father or Class Companion's Name ___________________________
Due Date __________________________
Name of Clinic ___________________________
Physician/Midwife _____________________________
Name of Insurance or Health Plan, Insurance Policy Number ____________________________________________________
Where will you be delivering _____________________________
For class dates and time, please refer to the
Birth Center Course Guide
| Name of Class |
Class Start Date |
Cost |
Childbirth Preparation Classes
Six-Week Evening Course |
|
$95 |
Childbirth Preparation Classes
Weekend Express Course
8/7 & 8/8 Class CANCELED |
|
$95 |
Childbirth Refresher Classes
Two-session Series |
|
$40 |
| Cesarean Childbirth Class |
|
$35 |
| VBAC - Vaginal Birth After Cesarean |
|
$35 |
Sibling Class
Names _______________ Ages _______ |
|
$20 |
| New Baby Class |
|
$25 |
| Breastfeeding Class |
|
$40 |
| Sign Language Class |
|
$45 |
| Infant CPR & Safety Class |
|
$40 |
| Baby and Me - Early Weeks |
|
$20 |
Birth Center Tour
No. Attending ______ |
|
FREE |
| TOTAL AMOUNT ENCLOSED |
|
|
*Does not include Infant Massage Series.
____ I have enclosed a check payable to Regions Hospital.
____ I wish to pay with a credit card. Complete credit card details below.
Credit Card Type: (check one)
____ Visa
____ MasterCard
____ Discover
____ American Express
Credit Card Number _________________________ (e.g., 12341234...)
Card Validation Code ________ (three digit code found on the back of card in signature area)
Expiration Date __________ (e.g., 01/04)
Card Holder's Name ___________________________________
Amount Charged to credit card _______________
