Health Improvement Program
» Class Registration
Untitled Document
Step 2: Register For Classes
Class Registration Form
Use this form to register for any clases the 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:
(Stanford Only
(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:
(Stanford Only)
Mail Code:
(4 digits)
*
*
Campus Phone:
(Stanford Only)
eg. (650)725-0000
Fax:
*
Health Plan:
- Select 2008 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: