HypnoBirthing Enrollment Form

HypnoBirthing Enrollment Form
Pregnant Parent's Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Birthing Companion (spouse, partner etc..)

First NameLast Name
Birthing Companion Email
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact's Phone Number

Area CodePhone Number
Birthing Assistant/ Doula

First NameLast Name
Care Provider Name & Title*
Birthing Facility*
City
When is baby expected (your estimated due date)?*
How many weeks pregnant will you be when you begin classes?*
Class Date and Time*
Any previous pregnancies?
Which class format do you prefer? Note: In person classes need a minimum of 2 couples*

In PersonVirtual
Anything else you would like me to know? (medical conditions, multiples...)
Where did you hear about HypnoBirthing/Estee's classes?
Class Deposit

prevnext( X )
USDClass deposit
Please note: By submitting your form with the class deposit, your spot will be reserved for you for the class date selected. The balance is due before the first class and can be paid via Zelle or Venmo. Details to follow.

I acknowledge:
- Estee Nadav does not provide medical advice.
- Deposits are non-refundable.
- There are NO refunds, at any point after the first class.
- Group class total is $400, private class total is $725 (deposit included).
By signing below you agree to the above terms.
Signature*

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