Perinatal Education
Class Registration Form

Cancellation Policy

Class may be canceled up to one month before the start date with refund less a $10 administrative fee. All other requests for refund will depend upon replacement for your reserved place. The $10 administration fee is non-refundable. Class texts and materials received during the first class or classes incur an additional $20 refund deduction.

PLEASE PRINT, COMPLETE, AND MAIL THIS FORM
TO THE ADDRESS INDICATED BELOW

NAME (Last) ______________________________(First)__________________________

NAME OF PARTNER ______________________________________________________
(NAME and AGE of CHILD for SIBLING Class)__________________________________________

ADDRESS ________________________________________________________________

CITY ___________________________________ STATE _________ ZIP ____________

DAYTIME PHONE (_______)________________________________________________

PHYSICIAN_______________________________________________________________

DUE DATE _______________ HOSPITAL _____________________________________

Handicap Symbol Please inform our registrar if you have any special needs.

CLASS/PROGRAM TITLE	CLASS START DATE First choice: Second choice:	FEE

PLEASE MAKE YOUR CHECK PAYABLE TO: LPCH

M/C ______	VISA _____	DISCOVER _____
*CARD #. _______________________________ EXP. DATE_______/______ __________________________________________________________________
CARDHOLDER NAME__________________________________________________________________
AMOUNT OF PAYMENT ___________________________________________________________________
SIGNATURE (cardholder)__________________________________________________________________

MAIL TO: or FAX TO: (650)724-7514	PERINATAL EDUCATION, RM P156
	Lucile Packard Children's Hospital
	725 Welch Road
	Palo Alto, CA 94304

Stanford University School of Medicine

Perinatal Education Class Registration Form

Cancellation Policy

Perinatal Education
Class Registration Form