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Birthing with Meshawn Registration
Please complete the form. All classes are currently being held virtually. Once completed please send payments via Paypal to
meshawn@forherinstitute.org
Please include HypnoBirthing in the note
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Today's Date
MM
/
DD
/
YYYY
Type of Services enrolling in
HypnoBirthing Class
Doula Care
Breastfeeding Education Session
Mom's Name
*
Your answer
Mom's Email
*
Your answer
Mom's Address
*
Your answer
Mom's Phone number
Your answer
Mom's Occupation
Your answer
Mom's Educational Level
Less than High school diploma
High school diploma
Bachelor's degree
Master's degree or higher
Clear selection
Mom's Age
Your answer
Birth Companion's Name
Your answer
Age
Your answer
Phone
Your answer
Occupation
Your answer
Email
Your answer
Healthcare Provider Name
Your answer
Healthcare Provider Phone
Your answer
Birth Facility
Your answer
Baby's Estimated Birth Day
MM
/
DD
/
YYYY
Previous births
Yes
No
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Previous Childbirth Class
Your answer
How did you learn about HypnoBirthing?
Your answer
Why have you chosen HypnoBirthing?
Your answer
Preferred Class Start Date
MM
/
DD
/
YYYY
Class preference
Individual couple (additional $50 cost)
Group
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First Choice for preferred Day of the week for class
Choose
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Second Choice for preferred Day of the week for class
Choose
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Any questions or comments
Your answer
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