Fern and Sage HypnoBirthing Registration Form
Thank you so much for taking the time to fill out this form, so I can get to know you better and have an idea of how I can best support you! Note that you will be asked to pay the $100.00 deposit by credit card after hitting submit on this form. If you would prefer to pay by another means, please email me.
Your Name
*
First Name
Last Name
Your Phone Number
*
-
Area Code
Phone Number
Your Birth Partner's Name (if applicable)
First Name
Last Name
Your Home Address
*
Street Address1
Street Address 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Your Email
*
example@example.com
Current Pregnancy Information
Estimate Due Date
*
-
Day
-
Month
Year
Date
Doctor/ Midwife's / Practice name
*
Doula's Name (if applicable)
Delivery Location
*
Home
Birth Center
Hospital
I'm not sure yet.
Address and name of delivery location if known:
How many weeks pregnant will you be when class starts?
*
Please indicate which type of class you are signing up for.
*
In-person Group HypnoBirthing Class ($399)
Online HypnoBirthing Class ($399)
Private HypnoBirthing Class
Refresher Course
Enter the start date of the class you are signing up for (e.g. August 12)
*
There is a $100.00 non-refundable deposit due at the time of submission of this form. The remainder is due by the first class. You can pay by credit card, cash, or check.
*
I acknowledge
If you are taking an in-person class at Trillium House, please acknowledge you understand that in the event of a birth taking place at the time of our class, we will move that day's class to virtual using Zoom.
*
I acknowledge
Not applicable. I'm taking an online or private class.
Please acknowledge that you understand the makeup class policies (free virtual or $60 in-person class for your first makeup and $60 for any subsequent makeup class regardless of location).
*
I acknowledge
How did you hear about me?
*
(Ex: Google, Instagram, Brochure, etc.)
Is there anything else you would like me to know?
Submit
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