Babies and You Delivery Notification Form

To qualify for the cash incentive for Babies and You, the Saturday class must have been taken at preconception or within your first trimester. To qualify for the Healthy Addition cash incentive, you must have enrolled by 21 weeks gestation or earlier.

Please complete the form below to receive the incentive for participating in one or both of these activities. The appropriate amount will be added to your paycheck as a Wellness Incentive and will be distributed in approximately 90 days . If you have any questions, please email jordan.schultz@polk-fl.net or call 863-648-3057.

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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. When was your baby born?

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* 7. I participated in the following...

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* 8. How did you hear about this program?

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* 9. Did you find the healthy babies program beneficial?

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* 10. Please provide any additional comments.

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