Online Enrollment Form -

Please enable JavaScript in your browser to complete this form.

Mother’s First and Last Name:

Partner's Name:

Partner's Relation to Mother:

Cell Phone

Alternate Cell Phone/Partner's Cell (in case we can't reach you)

Mother's Email:

Partner's Email (to receive class emails along with you)

Street Address

City

State

Zip Code

Mother's Date of Birth

Mother's Age:

Mother's Occupation:

Highest Degree Completed:

Partner's Age:

Partner's Occupation:

Highest Degree Completed:

Name of Doula (if applicable):

Birthing Facility:

Practitioner Name & Title (e.g. OB, Midwife):

Your Baby’s Guess Date:

Start date or month of HypnoBirthing class for which you’re enrolling:

How many weeks pregnant will you be at the start of class?

What number birth is this for you?

Do you have any special circumstances you'd like to share? (e.g. VBAC, placenta previa, twins, etc.)

How did you learn about HypnoBirthing of Connecticut (Cynthia Overgard)?

HypnoBirthing of Connecticut, LLC would like your permission to email you (e.g. class links, supplemental information, etc.) Your information will never be shared. Do we have your permission?

I hereby state that I am enrolling in the HypnoBirthing class at HypnoBirthing of Connecticut, LLC of my own free will and with the understanding that the content of these classes is in no way intended to be represented as medical advice nor as a suggestion for medical procedure or lack thereof. I am aware that I should seek the advice of a healthcare provider to answer all health-related issues surrounding my pregnancy, labor and birth. I therefore agree that I will in no way hold Cynthia Overgard, the instructor of the HypnoBirthing classes and the owner of HypnoBirthing of Connecticut, LLC or its representatives, or the HypnoBirthing Institute, its owner, or its representatives responsible for any issues or special circumstances that could arise as a result of my pregnancy, my labor, or the birth of my child. I further release HypnoBirthing of Connecticut, LLC and all its members, owners, contractors, employees, and their successors and/or assigns from any actions, liability and/or wrongdoings. 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. Please check the box if you agree:

Type your full name (Mother's electronic signature):