Group Course Enrolment Form – July / August 2022

Group Course Enrolment Form – July / August 2022

Please return your form and confirmation of paid deposit to: penelope@joyfulbirths.com.au
PREGNANT PERSON'S INFORMATION
Name *

First Name Last Name
Date of Birth *

Day Month Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Pregnant Person's Email *
example@example.com
Phone Number *

Phone Number
Occupation
BIRTH COMPANION AND ASSiSTANT INFORMATION
Birth Companion's Name *

First Name Last Name
Relationship *
Birth Companion's Email *
example@example.com
Occupation
Birth Assistant Name

First Name Last Name
Birth Assistant Relationship
EG doula, friend, etc
CARE PROVIDER INFORMATION
Name and Title *
Location
Birthing Facility *
Location
BABY INFORMATION
Is this your first, second, thrid, etc baby? *
When is your baby expected to be born? *
How many weeks pregnant will you be when the course starts? *
How did you hear about Joyful Births? *
PREGNANCY AND HEALTH INFORMAITON
Family Birth History
Pre-eclampsia, hypertension, gestational diabetes, chromosomal abnormalities, etc
Any psychological issues?
Depression, anxiety, history of post natal depression, etc
How has your pregnancy been so far?
Do you have any health or obstetric concerns?
COURSE ENROLMENT AND AGREEMENT

We wish to enroll in the HypnoBirthing® course with the following dates, times and location:

Sunday 24 July	10am – 12.30pm	Session 1: Setting the Stage
Sunday 31 July	10am – 12.30pm	Session 2: Falling in Love With Your Baby
Sunday 7 August	10am – 12.30pm	Session 3: Visualisation and Deepening
Sunday 14 August	10am – 12.30pm	Session 4: Overview of Childbirth
Sunday 21 August	10am – 12.30pm	Session 5: Birthing

Location: SoulPod Health & Healing, 14 Stanley Street Richmond, Victoria, 3121

Tuition fee: $660 (fee includes textbook, audio practice MP3’s, and handouts.)

To secure your place a $100.00 (non-refundable) tuition deposit is required. Full payment is needed before the first class. Bank Transfer via EFT.

Account Name: Joyful Births
BSB: 083004
ACC: 815127678

Please upload a photo to confirm payment of your deposit

Cancel of
The HypnoBirthing® Institute may contact you for quality assurance and research purposes. If you consent to be contacted now, please note that you are free to change your mind at any time. Be assured that we will not share your personal identifying information with anyone outside the HypnoBirthing® Institute for any purpose. Thank you for your help in collecting data to support the growth of HypnoBirthing ®.
Do you agree to be contacted by the HypnoBirthing Institute? *

Yes, we agree No, we don't agree
We hereby state that we are enrolling in the HypnoBirthing® class of our own free will and with the understanding that this is a program designed to teach us to use our own natural abilities to bring the mind and my body into a state of relaxation. We 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. We are aware that we should seek the advice of a health-care provider to answer any health-related or pregnancy-related issues surrounding our pregnancy, labour, or birth.

We therefore agree that we will in no way hold the instructor of the HypnoBirthing® classes, or the HypnoBirthing Institute®, its owner, or its representatives responsible for any special circumstances that could arise as a result of the pregnancy, labour, or the birth of our child; and we agree that neither us nor any member of our families will make any claim or initiate any suit against any of the above-named parties now or at any time in the future.
Pregnant Person's Signature *

Clear
Date *

Month Day Year
Date
Birth Companion's Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Group Course Enrolment Form – July / August 2022

PREGNANT PERSON'S INFORMATION

BIRTH COMPANION AND ASSiSTANT INFORMATION

CARE PROVIDER INFORMATION

BABY INFORMATION

PREGNANCY AND HEALTH INFORMAITON

COURSE ENROLMENT AND AGREEMENT