Childbirth Class Scholarship Application
Personal Information
Full Name *
Your answer
Street *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Email *
Your answer
Preferred phone number *
Your answer
Mother's birthdate *
MM
/
DD
/
YYYY
Baby's due date *
MM
/
DD
/
YYYY
Partner's full name
Your answer
Preferred phone *
Your answer
Provider's name *
Your answer
Provider's phone
Your answer
Where are you planning to have your birth?
Your answer
Is this your first birth? *
If no, what were your previous births like?
Your answer
How did you hear about Ypsi-Arbor CBE? *
Your answer
Which classes are you applying for fee assistance? *
Required
Dates you wish to attend *
Your answer
Fee Assistance Information
Please know that EVERY question must be answered in order for us to consider you for fee assistance. We will NOT process incomplete applications.
How many people live in your home? *
Your answer
What is your total household income before taxes? *
Your answer
Do you receive some sort of public assistance? If yes, please explain. *
Your answer
Do you have any specific needs or unique circumstances we should be aware of? *
Your answer
By clicking "Submit" I hereby recognize that all the above information I provided is true and correct, and understand that this information will not be publicly shared. I recognize that if I am accepted for fee assistance and sign up for the classes I am interested in, I have fully committed to attending these classes. Payment is due at the time of registration. If I am unable to attend the classes I am signed up for, I must give 48 hours advanced notice, or I will not receive a refund.
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