HypnoBirthing Registration HB Registration Your Name* First Last Birth Companion's NameHusband, partner, relative, friend... First Last Phone*Email* Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Care Provider NameBirth FacilityDoula's NameEstimated Due Date* Date Format: MM slash DD slash YYYY I wish to enroll in the following HypnoBirthing class:*Private SessionGroup SessionReferred byIf you were referred by someone, please let me know so I can thank them!Class FeeIf you pay a deposit now, then the balance will be due at the first class (unless otherwise arranged).Pay Deposit - $150Pay In Full - Group - $395Pay In Full - Private - $750Payment MethodPayPal: You will be directed to the PayPal platform to complete your payment upon submitting this form. Venmo: Please send payment to @Courtney-MenezesPaypalVenmoLiability WaiverI 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 therefore agree that I will in no way hold the instructors 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.By signing with your E-signature, you hereby agree to the above statements.*Please sign using your touchscreen device, touch pad or mouse. You may use the small circular 'refresh' icon below on the right to clear your entry and start again.EmailThis field is for validation purposes and should be left unchanged.
