[PHC Lake Jackson] HOPE Enrollment

First / Last Name

Birth Date

Email Address

Phone Number

Please select

Baby's Due Date

Please select

Baby's Father's First / Last name

Mailing Address

May we identify ourselves when we try to contact you? (You will receive a text reminder of class dates only)

Clear choice

Yes

Text Message Disclaimer**We are committed to protecting your health information. Please be aware that communicating via unencrypted/regular texting has some level of risk of being read by a 3rd party. By checking the 'Text Box' you acknowledge this risk.

Do you have other children?

Clear choice

Yes

Do you feel supported in this pregnancy?

Clear choice

Yes

How did you hear about HOPE?

Emergency Contact Name and Relationship to You

Phone Number

I give my permission for my/my baby's picture to be used in any publication or on the internet pages of the Pregnancy Help Center. All photos are understood to be the sole property of the Pregnancy Help Center.

Clear choice

Yes

By initialing in the designated area, you agree to each of the following terms of service regarding the HOPE program:

Classes are on Tuesdays from 5:00 p.m. – 8:00 p.m. Please be on time!

The HOPE entrance on the side will be locked at 5:01 p.m. If it is locked, you will need to enter through the front of the building and sign in. We will get you to class.

If you are going to be late or will miss a class, call us ahead of time and let us know (979-297-3622).

Missing 2 classes or being habitually late will prevent you from graduating from that Phase. You may attempt classes again at a better time for your schedule.-

We love children and babies, but they may not attend your class…except for the one in your belly.

You are welcome to bring a drink with a lid on it. Dinner will be provided for you, so you will not need food.

Our teachers are volunteering their time. Please be considerate of them during class and turn off your cell phones.

Confidentiality is extremely important. Please assist us by maintaining the privacy of your fellow parents, do not discuss other students, their names, or their situations outside of H.O.P.E. class. Compliance with our confidentiality policy allows all parents to feel confident, safe and able to participate.

Graduation will be held on the last Tuesday of each Phase around 8:00 PM. You may invite family members to attend and celebrate with you. They will enter through the front door, and we will escort them to the back.

A TEXT will be sent to you about one and a half weeks prior to your starting date. Please answer as soon as possible to let us know if you will be attending. If anyone will be coming with you, please let us know.

Notify us if your contact information changes so we can send you a reminder of class. We may also need to contact you during the program, especially in the case of a weather emergency.

Regarding Smoking- you may take a smoke break during your 30-minute meal break.

You agree to have your support person read these guidelines before coming to class.

Please initial in the box below.

I have read and understand the policies of HOPE classes led by Pregnancy Help Center. I understand what is required of me to attend the program.

Please type your name below if you agree with this statement.