Survey

In order to qualify for the $100 reimbursement, you must be either preconception or within your first trimester of pregnancy during the dates of the classes. You must attend all 3 classes in order to qualify for the reimbursement. If you have any questions, email allison.sullins@polk-fl.net.

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1. First Name

First Name

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2. Last Name

Last Name

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3. Worksite

Worksite

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4. SAP number

SAP number

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5. Email address (If you don't have one, please write "no email")

Email address (If you don't have one, please write "no email")

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6. Phone Number

Phone Number

7. When is your due date? (If not yet pregnant, write preconception)

When is your due date? (If not yet pregnant, write preconception)

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8. Select which class series you would like to attend:

Select which class series you would like to attend: Tuesday, June 12th from 8:30am-4:30 pm at Churchwell Elementary, 8201 Park Byrd Road, Lakeland

Thursday, June 14 from 8:30am-4:30 pm at Ridge Career Center, Community room

August 28th, Sept. 4th, Sept. 11th, 2012 at the Jim Miles Center Palmetto Room

Oct. 29th, Nov. 5th, Nov. 12th, 2012 at the Mark Wilcox portable, Winter Haven

January 29th, Feb.5th, Feb. 12th, 2013 at the Jim Miles Center Palmetto Room

April 8th, 15th and 22nd, 2013 at the Mark Wilcox Center portable, Winter Haven

*1. First Name

*2. Last Name

*3. Worksite

*4. SAP number

*5. Email address (If you don't have one, please write "no email")

*6. Phone Number