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*
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*

HomeBirth CenterHospitalI'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 ClassRefresher 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 acknowledgeNot 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?
Should be Empty:

Fern and Sage HypnoBirthing Registration Form

Current Pregnancy Information