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, HypnoBirthing Las Vegas, 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.

The undersigned acknowledge(s) the following: (1) HypnoBirthing Las Vegas is not an employee of Well Rounded Momma (“WRM”); (2) HypnoBirthing Las Vegas provides these services as an independent party; (3) WRM only facilitates by referral the relationship contemplated herein of the undersigned with HypnoBirthing Las Vegas; (4) WRM will not be held liable for any damages, court-related costs or suits naming HypnoBirthing Las Vegas.

I understand that refunds are not issued. If for any reason I do not complete the entire class series, I understand that I will not be issued a refund. I understand that private sessions are for my convenience and that instructors 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).

    Class Enrollment Form

    In the following form, 'mother' refers to expectant mother and 'partner' refers to expectant parent or support person. Please complete all applicable fields. * Fields must be completed for successful enrollment.

    *Accept Enrollment Agreement: I Accept

    *Preferred Class Type:

    Preferred Group Class Start Date:

    Second Choice Group Class Start Date:

    For private sessions please indicate your preferred days/times for classes and what date you'd like to begin:

    Expectant Mother's Information:

    *Full Name:

    *Mother's Age:

    *Estimated Due Date:

    *Current Weeks Pregnant:

    Order of Birth:

    *Address:

    *City:

    *State:

    *Zip Code:

    *Daytime Phone:

    *Type

    *Preferred E-Mail Address:

    *Mother's Occupation:

    Partner's Information
    Partner's Name:

    Partner's Age:

    Partner's Occupation:

    *Primary Birth Companion:

    Doula Information

    *Have you hired a doula: YesNo

    Doula's Name:

    Prenatal Care Information

    *Prenatal Care Provider:

    *Prenatal Care Provider's Name:

    Care Provider Attending Birth:

    If different than prenatal care provider, please complete the following questions.

    Birth Attendent's Name:

    Birth Location Information

    Birthing at:

    If birthing at a location other than home, please complete the following:

    Birthing Facility Name:

    Other Information

    Have you taken a previous childbirth class: YesNo

    If yes, what type of childbirth class:

    Location of previous childbirth class:

    *Where did you first hear about HypnoBirthing:

    *Where did you first hear about HypnoBirthing Las Vegas:

    If applicable, please list Referring Person/Source: