Fern and Sage HypnoBirthing Registration Form

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 NameLast Name
Your Phone Number
Format: (000) 000-0000.
Your Birth Partner's Name (if applicable)

First NameLast Name
Your Home Address

Street Address1

Street Address 2

CityState

Zip Code
Your Email
example@example.com
Current Pregnancy Information
Estimate Due Date

DayMonthYear
Date
Doctor/ Midwife's / Practice name
Doula's Name (if applicable)
Delivery Location
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.
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.
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.
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).
How did you hear about me?
(Ex: Google, Instagram, Brochure, etc.)
Is there anything else you would like me to know?
Should be Empty:

Fern and Sage HypnoBirthing Registration Form

Current Pregnancy Information