Thank you so much for your interest in the Baby College, please take a moment to fill out this pre-registration, and ensure that all information provided is valid.

If you have any questions or concerns, please email BabyCollege@hcz.org,  call 212-665-9832, or visit 2491 Frederick Douglass Blvd, New York, NY 10030

All information is kept confidential!

Adult 1 Information (Parent/Guardian/Grandparent)

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Date of Birth 

  Month Day Year
Please enter your date of birth

Question Title

* 4. Gender

Question Title

* 5. Street Address

Question Title

* 6. Apartment Number

Question Title

* 7. City

Question Title

* 8. State

Question Title

* 9. Zip or Postal Code

Question Title

* 10. Are you aware that virtual visits are a Baby College requirement?

Question Title

* 11. Cell phone Number, please enter using this format xxx-xxx-xxxx.

Question Title

* 12. Home phone number, please enter using this format xxx-xxx-xxxx.

Question Title

* 13. Email Address

Question Title

* 14. Preferred method of communication. Choose all that apply.

Question Title

* 15. Ethnicity 

Question Title

* 16. Race

Question Title

* 17. Primary Language

Question Title

* 18. Have you registered with us before? 

Question Title

* 19. How did you hear about us? 

Question Title

* 20. Are you pregnant?

Question Title

* 21. If yes, when is your due date?

Date

Question Title

* 22. If you are not pregnant, please select yes and provide the names of child(ren) ages 0 to 3 years old living in your household

 
 8% of survey complete.

T