Print this form, fill and mail to register. 		Back to Course & Tuition

                Course Enrollment

 

__________________________________________________________________________________

Mother’s Name

  

__________________________________________________________________________________       Mailing Address

 

_________________________________________ Preferred phone

 

_______________________________________ Alternate phone

 

_________________________________________

Preferred email

 

_______________________________________ Permanent Email

 

 _________________________________________________________________________________ Birthing Companion (spouse, partner, etc.)                      Relationship                                                                                  

 

_________________________________________

Birthing  Assistant

 

_______________________________________

Relationship (doula, friend, etc.)

 

_________________________________________

Care Provider Name & Title

 

_______________________________________

City

_________________________________________

Birthing Facility

 

_______________________________________

City

_________________________________________

When is baby expected?

 

 

______________________________________

How many weeks pregnant will you be when you begin classes?

I wish to enroll for the HypnoBirthing® class beginning (date):____________________________

 Location: ________________________________________________________________________

 Tuition fee: $275 for Group and $500 for Private Course

(Fee includes textbook, audio practice CD, and handouts.)

Discount available for clients with limited income.

 
Please send this form with a $50.00 tuition deposit.
 
Make Check Payable to
Gisela Llorens and mail to
7289 SW 53 Ave
Miami, FL  33143

Enrollment Agreement

 

The HypnoBirthingÒ 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 HypnoBirthingÒ Institute for any purpose.   Thank you for your help in collecting data to support the growth of HypnoBirthing ®.

I do ______ I do not _______  agree to be contacted by the HypnoBirthing® Institute.

I hereby state that I am enrolling in the HypnoBirthingÒ 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 HypnoBirthingÒ classes, or the HypnoBirthing InstituteÒ, 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.

 

Mother’s Signature                                                                                       Date