HypnoBirthing® Registration

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Please submit your answers to the following questions along with a deposit to secure your place in an upcoming class.

Email *

First & Last Name *

How many weeks pregnant are you? *

Estimated Due Date *

YYYY

Will this be your first birth? *

Yes

Phone # *

Are you looking for group or private classes? *

Please select preferred time(s) of day. *not guaranteed that your choice will be the actual time of class* *

Saturdays, 10am - 12:30pm EST

Saturdays, 11am - 1:30pm EST

Saturdays, 12pm - 2:30pm EST

Saturdays, 2:30pm - 5pm EST

Sundays, 10am - 12:30pm EST

Sundays, 11am - 1:30pm EST

Sundays, 2:30pm - 5pm EST

Other:

Required

Will you be having any of the below attend the class with you? *

partner

doula/birthworker

friend

family member

midwife/medical provider

If so, please share their first and last name below. *

Which investment method are you selecting?
*

$500 Group with a $100 deposit due upon enrollment.

I believe I qualify for sliding scale/payment plan or I have already been invited to join at a sliding scale rate or use a payment plan.

$650 Private with a $100 deposit due upon enrollment.

Shipping address for course materials *

Is there anything that you would like us to know about you before our class starts?

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 labour, or my birth.

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 labour, 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.

Please enter a yes or no to the above statement and your full name.

Today's Date *

YYYY

A copy of your responses will be emailed to the address you provided.

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