Maternity Program Form Download Form Section A - Member DetailsRewards for expecting mothers Register early on our Maternity & Baby Programme within 6 months of pregnancy / 3 months from confinement and receive N$200 wellness awards. Opt for a normal birth at 50% of maternity events and receive N$1,000 wellness awards.Membership Number (Existing)Existing Membership Number (Continuation members)Title*MsMrMrsMissDrInitials*Full Names*Surname*Telephone Number (Home)Telephone Number (Work)Cellphone NumberFax NumberEmail Address Marital StatusSingleMarriedDivorcedWidowedCommon LawSection B - Medical Details (To be completed by the Healthcare Professional.)Dependent NameDate of Birth DD MM YYYY AgeHealthcare Professional NameNormal DeliveryCaesarean (C-Section)Expecting Date DD MM YYYY Hospital NameOther medical treatment to be received?YesNoAttach doctors motivational documentsYesNoPlease give details if yes?Pre-Authorization NumberHealthcare Professional SignatureDate DD MM YYYY Section C - Employment Details (For office use only)PrivateCompanyCB NumberEmployment Date MM DD YYYY Administration NotesNote: If joining date of employment date differ, please provide details hereto?
