Birth Center tours and car seat safety classes form

In order to be eligible for a free car seat through this program, you must be enrolled in Hennepin Health, BluePlus, or UCare MA health insurance. Individuals with these plans are eligible if they are at least seven months pregnant or if they are a child age 0 -7. Please complete a new form for each individual receiving a car seat.

Haga clic aquí para registrarse en Español

  (Fill out 1 form per class)
* = required field
*First Name  
*Last Name  
*Address  
*City  
*State 
*Zip Code
*Language Requirement
Other language, if applicable
*Primary Phone
*eMail
*Birthdate  
Current HCMC Patient?
For your prenatal care, who do you see?  
Your Clinic Name  
Is this your  
first baby?  
Due Date  
* Class 
desired  

*Class  
date desired 

   
*Insurance Company**
 

**We bill insurance for the cost of most classes.

*Group Number
*Subscriber/Insurance Number

Thank you for completing this form!
 

Welcome to The Birth Center at HCMC's childbirth education video classes! Here you will find a variety of video topics to choose from. Please enter the password given to you by your provider.

Password: