January 2021 Hypnobirthing Australia™ Positive Birth Program

Hypnobirthing Australia™ Positive Birth Program - Enrolment Form
Congratulations on taking the exciting step to learn hypnobirthing and prepare for a beautiful and positive birth experience! The Hypnobirthing Australia™ Positive Birth Program includes:
- 12 hours of small group classes for the birthing mother and birth partner.
- Modern and relevant HypnoFolio of Resources, including course handouts, practice materials and visualisations.
- Deep relaxation/self hypnosis tracks (4 long play tracks) with self-hypnosis, music and affirmations.
- eBook ‘little book of hypnobirthing’.
- Practice video ‘Rehearsal for Birth’.
- Additional support from me right up until your birth.
JANUARY SMALL GROUP COURSE

My Wellness Chiropractic, 1036 Heidelberg Road, Ivanhoe

Session 1: Sunday 17th of January 2021 from 10am - 5pm

Session 2: Sunday 31st of January 2021 from 10am - 5pm
I wish to enrol in the Hypnobirthing Australia™ Positive Birth Program small group class run 10am-5pm on Sunday 17th and Sunday 31st of January 2021 at My Wellness Chiropractic in Ivanhoe.*

Yes
Mother's name:*
Mobile phone number:*
Alternate phone number (work / home etc.)
Email address:*
Address:*

Street Address

Street Address Line 2

SuburbState

Post Code
Birthing Companion (name of spouse / partner etc.)
Relationship to mother:
Birthing Assistant (if applicable):
Relationship (e.g. doula / friend etc.)
Care Provider name and title (e.g. Midwife / Doctor / Obstetrician)*
Hospital / Birthing Facility (name & location)*
When is baby expected?*
How many weeks pregnant will you be when you start class?*
Is this your 1st, 2nd, 3rd etc. baby?*
Is this birth a VBAC or is there any important information/medical conditions/psychological or psychiatric treatment you need me to be aware of before classes commence?
How did you hear about hypnobirthing classes with The Nurtured Seed?*
PROGRAM PAYMENT

The full cost of the course is $550, and a deposit of $150 is required with your enrolment to secure your place. This deposit is non-refundable unless The Nurtured Seed is no longer able to offer you a place in the course.

The remaining $400 is required no less that 7 days before the start of the course.
Please indicate which payment option you will be making today.*

PayPal / Credit Card $150 depositDirect Deposit $150 deposit
DIRECT DEPOSIT PAYMENT DETAILS

Account Name: Stephanie Dalo The Nurtured Seed

BSB: 062 692

Account Number: 3965 7049
FOR PAYPAL / CREDIT CARD PAYMENT - PLEASE SELECT YOUR OPTION AND PAYMENT TYPE
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Hypnobirthing Australia Positive Birth Program - DEPOSIT
$150.00AUD

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Hypnobirthing Australia™ Positive Birth Program - Enrolment Form

JANUARY SMALL GROUP COURSE