Hypnobirthing Course Agreement and Booking Form

Mothers Name *

First

Last

Birth Partners Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Estimated Due Date

Allergies/Food Intolerances/Preference *

Have you done a Hypnobirthing Class/Course previously

Yes
No

Are you having

One Baby
Multiple 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 agree

Hypnobirthing 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 agree

I would like to book *

4 x 2hr private sessions $795 Deposit - $ 150.00
2 x 4hr private sessions $795 Deposit - $ 150.00
4 x 2hr Group Class $595 May - June Deposit - $ 150.00
2 x 4hr Group Class $595 July or later Deposit - $ 150.00
1 day 6hr Private Intense Class $600 - $ 150.00
1 day 6hr Group Intense Class $475 - $ 150.00

Total Amount

$ 0.00

Signature

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