Registration

Please note, I am only booking private in person or virtual sessions at this time for

May - June 2025

Mother's Information

First Name

Last Name

Preferred Email

Alternate Email

Preferred Phone

Alternate Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Companion's Name

Birth Companion's Relationship

Birth Companion's Phone

Birth Companion's Email

Birth Assistant Name and Relationship

Doula, etc.

Birthing Facility

Birthing Facility City

When Is Baby Expected

How many weeks will you be when class begins?

I wish to enroll on this class date

Please select a start date below

Course Enrollment Agreement

I hereby state that I am enrolling in the HypnoBirthing® class of my own free will and with the understanding that this is a program designed to teach me to use my own 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 medical procedure. I am aware that I should seek the advice of a health-care provider to answer any health-related or pregnancy-related issues surrounding my pregnancy, my labor, or my birth. I give permission to my HypnoBirthing®Practitioner to use my email address for direct contact and understand that my email address will not be used in any other way. I therefore agree that I will in no way hold the instructor of the HypnoBirthing® classes, or the HypnoBirthing Institute®, its owner, or its representatives responsible for any special circumstances that could arise as a result of my pregnancy, my labor, or the birth of my child; and I agree that neither I nor any member of my family will make any claim or initiate any suit against any of the above-named parties now or at any time in the future.

*Terms and conditions:

A Non-Refundable deposit of $100 is made to hold your space in class. Then pay the remainder before class one. Class tuition must be paid in full before start of the series unless prior arrangements have been made. No refunds will be given after the first class has been taught. A "Welcome Email" will be sent within 24-48 hours upon enrollment.

Mother's E-Signature

First Name

Last Name

Birth Companion's E-Signature

First Name

Last Name

Date

YYYY

How did you hear about us?

Who referred you? Please provide their name and contact info.

Registration

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