2008 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	Deliver at Regions	Deliver Elsewhere
Childbirth Preparation Classes Six-Week Evening Course		$95	$120
Childbirth Preparation Classes Weekend Express Course		$95	$120
Childbirth Refresher Classes Two-session Series		$40	$55
Cesarean Childbirth Class		$35	$50
VBAC - Vaginal Birth After Cesarean		$35	$50
Sibling Class Names _______________ Ages _______		$20	$25
New Baby - New Parent Class		$45	$60
Breastfeeding Class		$40	$45
Infant Massage Series		$50	$50
Infant CPR & Safety Class		$45	$55
Birth Center Tour No. Attending ______		FREE	FREE
Six-Week Prenatal Class Series plus any 3 additional classes*		$195	N/A
Weekend Express Series plus any 3 additional classes*		$195	N/A
TOTAL AMOUNT ENCLOSED

*Does not include Infant Massage Series.

If paying with credit card, please complete the information below:

Credit Card Type:
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 _______________