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WELCOME TO THE BABEEZE.CO.ZA REGISTRATION PAGE

Please take a few moments to register your details with us. Kindly note that all information shared, is private and shall not be shared with any third parties unless your written consent has been requested and received.

Registration is a once-off.
We encourage you to please update your details directly on the website on a regular basis (so that we may provide you with ongoing and accurate information).
You will receive an e-mail from us shortly, thanking you for registering with babeeze.co.za
If you experience any problems and need to discuss with us, please contact lynne@babeeze.co.za
Should you wish to terminate your membership at any time, due to unforeseen circumstances, kindly email lynne@babeeze.co.za with your request.

BABEEZE.CO.ZA REGISTRATION FORM
(Items marked with an “*” are required):

MEMBER INFORMATION:

NAME:*
SURNAME:*
EMAIL ADDRESS:*
ID NUMBER:
TELEPHONE (Home):
TELEPHONE (Work):
TELEPHONE (Cell):*	Example: 27821234567
PASSWORD:*
RE-ENTER PASSWORD:*

OCCUPATION:
PROVINCE:*
SUBURB:*
NEWSLETTER:
ETHNICITY:*
WHERE DID YOU HEAR ABOUT BABEEZE.CO.ZA?:*
POSTAL ADDRESS:
PHYSICAL ADDRESS:
PHYSICAL ADDRESS CODE:
ARE YOU A DISCHEM BENEFITS MEMBER?*	Yes No
DISCHEM MEMBERSHIP NUMBER:*
WOULD YOU LIKE TO BECOME A DISCHEM BENEFITS MEMBER? :	Yes No
ARE YOU PREGNANT?:*	Yes No
PREGNANCY INFORMATION:
BIRTHING EXPERIENCE :*
EXPECTED DATE OF DELIVERY:*
HAVE YOU CHOSEN A HOSPITAL / CLINIC TO HAVE YOUR BABY?*	Yes No
WHICH HOSPITAL / CLINIC: *
DO YOU HAVE ANY OTHER CHILDREN ?:*	Yes No
EXISTING BABY/CHILDREN:
NUMBER OF CHILDREN YOU ALREADY HAVE:*

WOULD YOU LIKE TO RECEIVE INFORMATION ON THE FOLLOWING:
WOULD YOU LIKE TO JOIN THE MEDI-TWINKLE (MEDI-CLINIC) PROGRAMME? :	Yes No
WOULD YOU LIKE TO RECEIVE INFORMATION ON MEDI-CLINIC DOCTORS AND HOSPITALS? :	Yes No
WOULD YOU BE INTERSTED IN ATTENDING A BABEEZE WORKSHOP? :	Yes No


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