register for a class

Name of Mother-To-Be *
Date of Birth (MM/DD/YY) *
Mailing Address With Postcode *
Home Phone No. *
Work or Mobile Phone No. *
Email *
Birthing Companion's Name *
Birthing Companion's Relationship To You *
LMC / Care Provider Name *
LMC Contact No. & Email *
Birthing Facility *
Baby's Expected Due Date (MM/DD/YY) *
Is this your first baby? * Yes
No
How many weeks pregnant will you be when you start the course? *
I wish to enroll in: *
Starting in: *
Please note:A $75.00 non-refundable deposit is required to secure your place on the course. Registration alone is not sufficient. The full balance is due before the commencement of your course. Payment options will be provided following the submission of this registration form.
Enrollment 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®.
I agree to be contacted by the HypnoBirthing® Institute
Digital Signature *
Today's Date (MM/DD/YY) *
By typing my name (digital signature) above 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 labour 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 labour, 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.
How did you hear of Auckland HypnoBirthing Classes? *
Other
Thank you.