Hypnobirthing Course Agreement and Booking Form Please enable JavaScript in your browser to complete this form.Mothers Name *FirstLastBirth Partners Name *FirstLastEmail *Phone *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryEstimated Due DateAllergies/Food Intolerances/Preference *Gluten FreeDairy FreeCeliacVeganVegetarianRed Meat AvoidanceOtherNilHave you done a Hypnobirthing Class/Course previouslyYesNoAre you having One BabyMultiple Babies I hereby state that I am enrolling in the session 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 healthcare 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 session/s, or Hypnobirthing Australia™ / Hypnobubs®, its owner, or its representatives responsible for any special circumstances that could arise as a result of my pregnancy, my labour, the birth of my child or recovery; and I agree that neither I nor my birth partner or 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. In respect for privacy for the families who have allowed their private videos and photos to be included in the course content; I agree not to photograph, video, screen-capture, record, share or upload to the internet any of the content shared in these sessions. *I agreeHypnobirthing Australia™ / Hypnobubs® may contact you for quality assurance and research purposes in the future. If you consent to be contacted, please note that you are free to change your mind at any time. Be assured that we will not share your personal identifying information with anyone outside Hypnobirthing Australia™ / Hypnobubs® for any purpose. Thank you for your help in collecting data to support the growth of hypnobirthing. Please tick I do/ I do not agree to be contacted by Hypnobirthing Australia™/ Hypnobubs® for research/quality assurance purposes. *I do agree I do not agreeI would like to book *2 x 4hr private sessions $795 Deposit - $ 150.002 x 4hr Group Class $595 Deposit - $ 150.001 day 6hr Private Intense Class $600 - $ 150.001 day 6hr Group Intense Class $475 - $ 150.00Group Course Intensive 6hr course datesGroup Course 2-5 x Couples 30th JanGroup Course 2-5 x Couples 13th FebGroup Course 2-5 x Couples 27th MarchGroup Course 2 x 4hr dates (dates yet to be Set)Group Course 2-5 x Couples FebGroup Course 2-5 x Couples MarchGroup Course 2-5 x Couples AprilGroup Course 2-5 x Couples MayTotal Amount$ 0.00SignatureClear SignatureCaptcha * = We would love to know where you found out about usFacebookGoogleWord of MouthShop a docketHealth Care providerSubmit Share this:TwitterFacebookLike this:Like Loading...