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Registration Form

You do not need to register for Great Expectations, Little Fingers/ Little Toes or Breastfeeding classes. Please check the class schedule carefully for location and time as it varies. We urge you to take the Great Expectations class first as a good introduction to having your baby at Baptist Health Lexington.

You do not need to register for Great Expectations, Little Fingers/Little Toes or Breastfeeding.

Map

We recommend you print a copy of your selections from this page for your files, or use the printer-friendly version to print a handwritten form for faxing.

Registrant Information

* Required Fields

* 1^st Registrant Name
2^nd Registrant Name
Parent's Name		Parent's Name and Registrant Age are needed for the New Brother/ New Sister (Sections 1 & 2) and Safe Sitter classes only.
Registrant Age
* Address
* City:	* State: * Zip:
* Primary Phone
* Email
* Physician's Name
* Due Date
Baptist Health Lexington Employee	Yes No

Class Information

Please indicate the class(es) and date(s) you would like to attend:

Class	Date (mm/dd/yyyy)	# Attending
Comfort Measures for Childbirth
Laboring the Natural Way
Marvelous Multiples
New Brother/New Sister Section 1 (Ages 3-7)
New Brother/New Sister Section 2 (Ages 8-11)
Pediatric CPR (PCPR and First Aid : $30 per person; $45 per couple; $15 each additional caregiver)
Safe Sitter ($75 per child) (Payment must accompany registration)

Sibling Information

Please list the name(s) of the sibling(s) planning to attend.
For New Brother/New Sister (Sections 1 & 2) classes only.

Sibling Full Name		Age
Sibling Full Name		Age
Sibling Full Name		Age
Sibling Full Name		Age

Credit Card Information

NOTE: Credit card information is only necessary for those classes that require payment.
Only the Pediatric CPR and Safe Sitter classes require payment at time of registration.

Type:
Name on card:
Account Number (without spaces):
Expiration Date:
Amount to be Charged:	$

Additional Information

How did you learn about our Childbirth classes?
Physician	Radio
Friend/Relative	TV
Newspaper	Website
Other

Comments

Do you have any additional comments?

A 24 hour notification of cancellation is required for a refund of your registration fee.

To pay by check, complete this form and print it.
Mail it with your check made payable to Baptist Health Lexington to:

HealthwoRx
1740 Nicholasville Rd.
Lexington, KY 40503

For questions or scholarship information please call:
(859) 260-6357
Fax (859) 260-4153