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HypnoBirthing Class Registration Form
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Start date of Class Series you wish to attend: *
Mother's First & Last Name *
Birth Companion's First & Last Name *
Mother's Preferred Email Address *
Home/Mailing Address *
Street, City, and Zip Code
Mother's Occupation *
Birth Companion's Preferred Email *
Mother's Preferred Phone Number *
Birth Companion's Occupation *
Birth Companion's Preferred Phone Number *
Birth Companion's Relationship to Mother *
(i.e. Partner, Husband, Wife)
Doula/Support Person *
Someone other than your Birth Companion, be it a Doula, Friend, Sister, please put their name if applicable. If you are considering hiring a Doula but haven't found one yet, please put "Doula Wanted"
Care Provider Name, Type & City *
(OB/GYN, Licensed Midwife, Certified Nurse Midwife, etc.)
Name of Birthing Facility *
(i.e. Home, Birth Center, Hospita)
Estimated Guess/Due Date *
MM
/
DD
/
YYYY
How many weeks pregnant will you be at the start of class? *
Any previous pregnancies/births? *
We are having... *
How did you hear about us? *
Tell me what you're most excited to learn! *
Anything else you would like me to know? *
Multiples, religious/cultural considerations, severe medical conditions/complications, etc.
Will you be joining us... *
In order to reserve my spot in class, I agree to pay the... *
Please return to the previous page to complete your payment.
If you'd like a receipt to submit to your insurance, please type the full name you like on it.
First and Last Name
Enrollment Agreement *
I/We (parents) hereby state that I am enrolling in Wise Women Medicine's childbirth class of my own free will. I/We understand that this is a program designed to teach me how to use my innate, natural abilities to bring my mind and my body into a state of relaxation. I/We further understand that the content of these classes is in no way intended to be represented as medical advice, nor as a recommendation for any particular medical procedure. I/We also understand that I need to seek the advice of a medical provider to answer any questions related to my health, pregnancy, labor, birth and postpartum. I/We agree that I/We will in no way hold the instructor, Rachel Flores, or its representatives responsible for any special circumstances that could arise as a result of my pregnancy, labor, or the birth of my child. I/We agree that neither I/We, nor any member of my family will make any claim, or initiate a lawsuit against the above-named parties now, or at any time in the future. I/We understand that my paid deposit, or 50% of my full payment, is non-refundable. I/We also understand that no refunds of any monies paid above the non-refundable deposit will be returned after the date our class series is scheduled to begin. Should I/We change our minds about class enrollment and want to request a refund of the monies paid above the 50% deposit, I/We agree that a written request will be emailed no less than 7 days prior to the beginning of my scheduled class series. I/We understand that birth, by nature, can be unpredictable. If Rachel needs to attend a birth on one of our regularly scheduled classes, or if for any reason our in-person class needs to be rescheduled, a recording of the class can/will be substituted. I/We also understand that if a scheduled series does not meet minimum enrollment requirements, the start dates may be extended by 1-2 weeks or cancelled (at which point, any all monies paid will be refunded). By clicking the button below, I/We hereby agree to the aforementioned terms in this Enrollment Agreement.
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