Inspired Birth Live Series Registration Form

Name

First Name Last Name

Estimated Due Date

Date

Planned Birth Location/Provider

Email

example@example.com

Phone Number

Area Code Phone Number

Birth Partner's Name

First Name Last Name

Tell us how you found Inspired Birth.

My Doula recommended the class. My Provider recommended the class. Social Media. Internet Search.

As of May 1, 2020 all classes will be held virtually via the Zoom platform until further notice to comply with County, State and Federal safety recommendations.

Inspired Comfort Measures Intensive Enrollment Agreement

Thank you for choosing Inspired Birth for your childbirth preparation education. This class is a comprehensive Comfort Measures class that will primarily focus on natural childbirth support. We trust that the many benefits that this program offers will help you to achieve the very best possible birth for your family. We look forward to working with you to provide the information you need to achieve the birth you desire.

This class will last 3 hours. This class will be held via Zoom online until further notice per County, State and Federal recommendations. Important topics that we will cover include but are not limited to: Breathing, Fear, Anxiety and Relaxation in Birth, Labor Coping Techniques, Partner Support Techniques, Comfort Measures for Labor.

** Please note that your partner should plan to attend this class with you to fully benefit from the hands on partner support techniques taught in this class.

Your class will be completed per the listed time and day schedule. Your instructor must be notified of any exceptions to this arrangement, i.e.: illness, scheduling conflicts, childcare difficulties, etc., no later than 2 hours prior to your scheduled class. Likewise, your instructor will notify you of any scheduling conflicts no later than 2 hours prior to your meeting as well.

The cost for this Comfort Measures Class series is $85. This is payable in full at the time of your registration unless previous arrangements are made. Refunds are not typically given and will be at the discretion of your instructor.

I hereby state that I am enrolling in the Inspired Birth Comfort Measures Intensive Class of my own free will and with the understanding that this is a program designed to teach me the important information I will need for myself and my partner to advocate for our family during our birth experience. This class will also help to enable me to use my own natural abilities to bring my mind and my body into a state of relaxation for labor coping. I further understand that the content of these classes is in no way intended to be represented neither as medical advice nor as a prescription for medical procedure. I am aware that I should seek the advice of a health-care provider to answer any health-related or pregnancy-related issues surrounding my pregnancy, my labor, or my birth.

I therefore agree that I will in no way hold the instructor of the Inspired Birth Comfort Measures Intensive, its owner, or its representatives responsible for any special circumstances that could arise as a result of my pregnancy, my labor, or the birth of my child; and 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.

This agreement is being signed via JotForm and you will be emailed a copy of your agreement when you sign. Please let your instructor know of any questions you might have at any point in your series or after.

Email address: info@inspiredbirth.com.

Your Inspired Birth Instructor is: Tracie Lynch

www.inspiredbirth.net

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Date

Name of Person Signing Form

First Name Last Name

My Products

Comfort Measures Intensive Stand alone, three-hour hands on partner support comfort measures class. **Comfort Measures curriculum is included in the three-week Inspired Birth Series.

$ 85.00

Total

$ 0.00

Payment Information

Thank You for registering for Inspired Birth Comfort Measures Intensive.