Health Improvement Program
» Class Registration
Untitled Document
Step 2: Register For Classes
Class Registration Form
Use this form to register for any classes that you will
pay for by check or credit card only
. To register for a class, please complete the following information (or include it on the form you will be asked to send in). Click on the "
Submit
" button once you have completed this form.
(
*
= Required Fields)
(
**
= Required Fields for Stanford University Employees)
Class Registrant Information
*
Name:
First
MI
Last
*
Gender:
Gender
Female
Male
*
E-Mail Address:
Employment Information
*
Employment Status:
- Select Employment Status -
Faculty
Univ Exempt
Univ Non-Exempt
SHC/LPCH Staff
Retiree
Family of Staff Employee
Community
Other
*
*
Employee ID:
(For University Employees only. SHC Employees, leave this field blank. Eight-digit number located on your Faculty/Staff ID. Your employee ID should be 8 digits long. If your employee ID is 9 digits long, please drop the first leading 0.)
*
*
Department:
Mail Code:
(4 digits)
*
*
Campus Phone:
eg. (650)725-0000
Fax:
*
*
Health Plan:
- Select Current Health Plan -
Blue Shield PPO
Blue Shield High Deductible PPO
Kaiser Permanente
HealthNet
Pacificare
Other
Contact Information
Home Phone:
eg. (650)725-0000
Address:
City/State/ZIP:
NEW!
We are introducing a new feature where we can update you with last minute changes via your mobile phone. We will only use this for class alerts. If you want to receive a text message alert on your mobile phone for any class updates or cancellations, please give us the following:
Mobile Phone Carrier:
Alltel
AT&T
Nextel
Sprint
SunCom
T-mobile
VoiceStream
Verizon
Only the listed carriers are supported.
Mobile Phone:
(digits only: eg. 5551234567)
Note: Standard text messaging charges may be applied by your carrier.
Please note: HIP will continue to send class updates such as class cancellations due to illness or changes in class location via email.
Class Information
This form allows you to "pre-register" for a maximum of three classes at a time. If you want to sign-up for more classes, you can complete the process for the first three classes and then return to this page and repeat as necessary.
*
ClassID1:
ClassID2:
ClassID3:
Many of our classes have limited enrollment. Thus, we want to ensure that registered participants actually attend. We ask that all of our participants make an honest effort to attend at least 50% of the class sessions.
I acknowledge and agree to the above statement.
