eLearning Childbirth Education Program

Please fill in and submit this registration form. All fields are required.

First:
 Required. Your first name is required.
Middle:
 Required.
Last:
 Required. Your first name is required.
Email Address:
 Required.Invalid format. Your first name is required.
Address:
 Required. Your first name is required.
City, State:
 Required. Your first name is required.
Zip: Required.Invalid format. Your first name is required.
Daytime Telephone:
 Invalid format.Required. Your first name is required.
Evening Telephone:
Invalid format.Required.
Date of Birth:
 A value is required.Invalid format (mm/dd/yyyy).
Due Date:
 A value is required.Invalid format (mm/dd/yyyy).
Physician's Name:
 Required.
Support Person's Name:
 Required.
Where did you hear about this class?:
 Required.
Are you a WIC patient?
 Yes
Have you used Stormont-Vail services before?
 Yes Please make a selection.
Are you delivering at Stormont-Vail?
 Yes Please make a selection.
If no, where are you delivering?
  A tour of the Birthplace is available with your registration fee.
If you want to schedule one, please call Laura Hortenstine (785) 354-5034 to schedule.
There is a $60 fee per registration.
Your total fee for eLearning Childbirth Education
Program is $60.

Make checks payable to Stormont-Vail HealthCare
and mail to:
Stormont-Vail HealthCare
Attn: Lynsay McElroy, Breastfeeding Clinic
1500 SW 10th Ave., Topeka, KS 66604-1353