Online Enrollment Form - HypnoBirthing of Connecticut

HypnoBirthing of Connecticut, LLC, Course Enrollment Form

Mother’s 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 (if he/she wants class updates, too)
Street Address*
City*
State and Zip Code*
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?*
Have you taken previous childbirth classes?*
- No
- Yes
If so, which one(s)?
How did you learn about HypnoBirthing of Connecticut (Cynthia Overgard)?*
Enrollment Agreement
HypnoBirthing of Connecticut, LLC, would like to include you in occasional email correspondence, including a bimonthly newsletter and the welcome email and childbirth-related resource information that is regularly sent to all class members as a part of the HypnoBirthing of CT course curriculum. Your information will never be shared.
Do we have your permission?*
- Yes
- No
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 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 or lack thereof. I am aware that I should seek the advice of a health-care 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 manager of HypnoBirthing of Connecticut, LLC 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 :*
- I agree
Do you have any special circumstances (twins, VBAC, etc.) or any additional information you would like to share?
Please enter your name in the field below to certify that (1) you have fully read and understand this enrollment agreement, and (2) you understand this acts as your electronic signature, which is legally binding.
Type your full name (Mother's) :*