HypnoBirthing Class Registration Form
Start date of Class Series you wish to attend: *
Mother's First & Last Name *
Your answer
Birth Companion's First & Last Name *
Your answer
Home/Mailing Address *
Street, City, and Zip Code
Your answer
Mother's Occupation *
Your answer
Mother's Preferred Email Address *
Your answer
Mother's Preferred Phone Number *
Your answer
Birth Companion's Occupation *
Your answer
Birth Companion's Preferred Email *
Your answer
Birth Companion's Preferred Phone Number *
Your answer
Birth Companion's Relationship to Mother *
(i.e. Partner, Husband, Wife)
Your answer
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"
Your answer
Care Provider Name, Type & City *
(OB/GYN, Licensed Midwife, Certified Nurse Midwife, etc.)
Your answer
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? *
Your answer
Any previous pregnancies/births? *
Your answer
We are having... *
How did you hear about us? *
Your answer
Tell me what brought you to HypnoBirthing, and what you're most excited to learn! *
Your answer
Anything else you would like me to know? *
Multiples, religious/cultural considerations, LGTBQIA+, severe medical conditions/complications, etc.
Your answer
Are you interested in the Breastfeeding & Postpartum Class? *
In order to reserve my spot in class, I agree to pay the... *
Please return to the previous page to complete your payment.
Enrollment Agreement *
I hereby state that I am enrolling in the HypnoBirthing class of my own free will. I 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 further understand that the content of these classes is in no way intended to be represented as medical advice, nor as a prescription for any particular medical procedure. I 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 agree that I will in no way hold the instructor of this HypnoBirthing class, the HypnoBirthing Institute®, 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 agree that neither I, 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 understand that my paid deposit is non-refundable. I also agree that no refunds of any monies paid will be given after I have attended the first class. I understand that birth, by nature, can be unpredictable. If Rachel needs to attend a birth on one of our regularly scheduled classes, class may be rescheduled, or a substitute will be made available. I also understand that if a scheduled series does not meet minimum enrollment requirements, the start dates may be extended by 1-2 weeks. By clicking the button below, I hereby agree to the aforementioned terms and agreement.
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