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In order to claim the reimbursement for participating in Babies and You or Healthy Addition, please complete the form below. In order to qualify for the reimbursement for attending the Babies and You classes, you must have taken them during preconception or within your first trimester. Attendance at all 3 classes is required. In order to qualify for Healthy Addition, you must have enrolled by 21 weeks gestation or earlier. 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. Current address (where the reimbursement will be sent)

Current address (where the reimbursement will be sent)

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7. When was your baby born?

When was your baby born?

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8. I participated in the following...

I participated in the following... Babies and You classes (completed during preconception or within first trimester)

Healthy Addition, Blue Cross Blue Shield program

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1. First Name

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2. Last Name

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3. Worksite

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4. SAP number

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

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6. Current address (where the reimbursement will be sent)

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7. When was your baby born?

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8. I participated in the following...

9. Did you find the healthy babies program beneficial?

10. Please provide any additional comments.

*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. Current address (where the reimbursement will be sent)

*7. When was your baby born?

*8. I participated in the following...

9. Did you find the healthy babies program beneficial?

10. Please provide any additional comments.

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1. First Name

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2. Last Name

*
3. Worksite

*
4. SAP number

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

*
6. Current address (where the reimbursement will be sent)

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7. When was your baby born?

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8. I participated in the following...