HypnoBirthing Class 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 understand that a painless birth is in no way guaranteed as many factors will influence my labor and birthing.

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 procedures. I am aware that I should seek the advice of a medical doctor or midwife to answer any health-related or pregnancy-related issues surrounding my pregnancy, my labor, or my delivery.

I, therefore, agree that I will in no way hold the instructor(s) of the HypnoBirthing classes, HypMama or the HypnoBirthing Institute, its owner, or its representatives, responsible for any complications that could arise as a result of my pregnancy, my labor, or the delivery 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.

I understand that private sessions are for my convenience and that instructor must make arrangements to accommodate my schedule. I, therefore, agree to pay a $50 fee for failure to provide adequate notification (minimum of 4 hours) in the event that previously scheduled sessions need to be rescheduled (for private sessions only; this fee will be waived in the event of true emergency situations and active birthing).

1. Enroll for HypnoBirthing Classes with HypMama
2. Accept Enrollment Agreement
3. Class Type please choose your preferred class type group private course private intensive (required)
4. Class Date please choose your preferred class Saturdays: Jan 24, 31, Feb 7, 21, 28 Saturdays: March 21, 28, April 4, 18, 25 I want private classes (required)
5. For private sessions please indicate your preferred days/times
6. Expectant Mother's Information
7. Email(valid email required)
8. Please repeat email(valid email required)
9. Your Name (First Last)(required)
10. Maiden Name(required)
11. Age(required)
12. Estimated Due Date(required)
13. Current Weeks Pregnant(required)
14. Order of Birth first baby second baby third baby fourth baby fifth baby more than five (required)
15. Address(required)
16. City, State(required)
17. Zip Code (xxxxx)(required)
18. Daytime Phone (xxx) xxx-xxxx(required)
19. Type
20. home mobile work
21. Occupation
22. Employer
23. Work Address
24. Education Level please select one doctorate masters bachelors associates high school graduate(GED) some high school
25. Expectant Father's Information
26. Name
27. Age
28. Occupation
29. Education Level please select one doctorate masters bachelors associates high school graduate(GED) some high school
30. If your birth companion is different than father, please complete the following
31. Birth Companion's Name
32. Birth Companion's Address
33. Birth Companion's Age
34. Doula Information
35. Have you hired a doula please select one yes no
36. Doula's Name
37. Doula's Address
38. Doula's Phone (xxx) xxx-xxxx
39. Prenatal Care Information
40. Prenatal Care Information please select one Family Docter General Practitioner Homebirth Midwife Hospital Midwife OB or OBGYN Other (required)
41. Provider's Name(required)
42. Provider's Phone (xxx) xxx-xxxx
43. Provider attending birth please select one Family Docter General Practitioner Homebirth Midwife Hospital Midwife OB or OBGYN Other
44. If different than your prenatal care provider, please complete the following
45. Birth Attendent's Name
46. Birth Attendent's Address
47. Birth Attendent's Phone (xxx) xxx-xxxx
48. Birth Location Information
49. Birthing at please select one home hospital other (required)
50. If birthing at a location other than home, please complete the following
51. Facility Name
52. Facility Address
53. Facility Phone (xxx) xxx-xxxx
54. Other Information
55. Have you taken a previous childbirth class?
56. yes no
57. If yes; what type of childbirth class?
58. Location of previous class
59. Where did you first hear about HypnoBirthing?
60. Where did you hear about HypMama?(required)
61. If applicable: please list referring person/source
62. Ten minus five equals

 

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Feel free to contact HypMama with questions/inquiries.