Course Enrollment

Mother’s Name

Birthing Companion’s Name (spouse, partner etc.)

Home Address

City, State/Province, Zip/Postal Code

Mailing address (if different from Home)

Please share my email address with other students in my class

Phone Number

Additional Birthing Assistants – Name and relationship to you

How did you hear about us?

Care Provider – Name and Title (ie OB, Midwife, etc.)

Where do you plan to give birth?

When is baby expected?

How many weeks pregnant will you be when you begin classes?

I wish to enroll in the session of HypnoBirthing® Classes starting on:

Friend Referral’s name (if registering with a friend, to be eligible for $50 discount):

Other Details (First baby? Details of previous birthing experiences? etc.)