HypnoBirthing Class Registration Form
Start date of Class Series you wish to attend: *
Mother's First & Last Name *
Birth Companion's First & Last Name *
Home/Mailing Address *
Street, City, and Zip Code
Mother's Occupation *
Mother's Preferred Email Address *
Mother's Preferred Phone Number *
Birth Companion's Occupation *
Birth Companion's Preferred Email *
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 brought you to HypnoBirthing, and what you're most excited to learn! *
Anything else you would like me to know? *
Multiples, religious/cultural considerations, severe medical conditions/complications, etc.
Are you interested in taking 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 recording of the class with be substituted. I 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 monies paid will be refunded). By clicking the button below, I hereby agree to the aforementioned terms and agreement.
Required
Current Health Concerns *
I understand that based on the current health climate, I can choose to attend class in-person or virtually. In-person classes will be limited to under 10 persons. I understand that the current California guidelines to wear face coverings is not law and is not required to attend class in-person; however, I know I may wear one if I desire. I understand that there may be other persons in the class who do not wear face coverings because it would negatively affect their health and well-being. I understand that each live class will be available to attend via Zoom if I would rather meet virtually. I agree to attend classes virtually if I am feeling unwell, showing signs or symptoms of sickness, or if I've received/plan to receive the Covid Shot. I agree that I will in no way hold the instructor of this Hypnobirthing class, or its representatives responsible for any special circumstances that could arise as a result of attending class in-person. I agree I am solely responsible for my health and 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.
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy