REGISTRATION FORM
CHILDBIRTH EDUCATION CLASSES
FOXCARE CENTER

Please print this page and then fill it out.

Mail to:

A.O. Fox Hospital
c/o Head Cashier
One Norton Ave.
Oneonta, N.Y. 13820

Name: _____________________________

Address: __________________________

___________________________________

___________________________________ (include Zip Code)

Daytime Telephone: ______________

Evening Telephone: ______________

Coach: _______________

Due Date: ____________

Doctor or Midwife: ____________

Are you receiving PCAP or MOMS?

__ Yes. Your course fees has been paid through PCAP or MOMS.
__ No. Course fees are as follows:

Please enclose payment made payable to A.O. Fox Hospital as follows:

Patients delivering at Fox Hospital:
__ Complete Course $30.00
__ Refresher Course $15.00

All other patients:
__ Complete Course $40.00
__ Refresher Course $20.00