HypnoBirthing Course Enrolment Form

Course Enrolment Form
Pregnant Person’s Name

First NameLast Name

Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Email
example@example.com

Birth Companion's Name (person attending the course with you)

First NameLast Name
Relationship

Midwife/Birthing Assistant Name

Name Last name
Relationship
(Midwife, doula, friend. etc).

Birthing Facility
(Home, Hospital or Birthing Centre)
City

Have you birthed before?
Yes/No
What baby number is this?
1st/2nd/3rd...

When is baby expected?
"Due Month" (e.g.: early January, middle January, late January)
How many weeks pregnant will you be when we begin classes?

Do you have any health or obstetric concerns?

I wish to enroll for the 5 Week HypnoBirthing® Course beginning:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Location/Format

Photo/Video Consent (optional):

From time to time, I may capture a few small moments during parts of our sessions to help illustrate my work and the HypnoBirthing approach on social media. I have done this previously with the consent of participating families, always with great sensitivity and respect for each couple’s privacy.

Images or videos may be taken from behind, in silhouette, or using discreet framing, and the lighting during our practices will always remain soft and calm. Participation is completely optional, and you are very welcome to opt out if you prefer.
Please select the option that best represents your preference as a couple:

Course Spot Confirmation

To secure your spot in the course, an initial payment of $150 NZD is required. This amount will be deducted from the total course fee, which must be fully paid before the program begins. The initial payment includes the materials you will receive during our first class and throughout the course.

Bank details:
Name: Soul Treat / Ethel Zegers
Bank: ANZ
Reference: HB enrolment
Account number: 06-0556-0975639-00

It will be an honour to support you during this special stage.

Enrolment Agreement:

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®.
Please select one:
I hereby state that I am enrolling in the HypnoBirthing class of my own free will and with the understanding that this is a program designed to teach me to use my own natural abilities to bring my mind and my body into a state of relaxation.

I 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. I am aware that I should seek the advice of a health-care provider to answer any health-related or pregnancy-related issues surrounding my pregnancy, my labor, or my birth.

I therefore agree that I 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 my pregnancy, my labor, or the birth of my child; and I agree that neither I nor any member of my family will make any claim or initiate any suit against any of the above-named parties now or at any time in the future.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: