Enrollment Form

HypnoBirthing®--the Mongan Method

Care M. Messer- CHBE, CD(DONA)
Ashley Wylie-Caldwell- CHBE, MA
Laura Magnarelli - CHBE, CD(DONA)

www.SanDiegoHypnoBirthing.com

For questions call: 858.254.9515

Course Enrollment Information Form

Mother's Information
First Name:
Last Name:
Mailing Address:
City:
State:
Zip Code:	(5 digits)
Preferred Email:
Alternate Email:
Preferred Phone:
Alternate Phone:
Birth Companion & Birth Assistant Information
Birth Companion Name:
Birth Companion Relationship:	(spouse, partner, etc)
Birth Companion Phone:
Birth Companion Email:
Birth Assistant Name:
Birth Assistant Relationship:	( Doula, Friend, Mom, etc)
Baby Information
Birthing Facility:	(Hospital/Birth Center)
City:
When is baby expected?:
How many weeks pregnant when class begins?	(ie 30 weeks)
Gender:
Class Information
Class to enroll in::
Property Information
Payment Type:	Make checks payable to "San Diego Hypnobirthing" I paid in full online I paid deposit online and will make both payments online Deposit and 2 postdated check payments enclosed Other
Other Information
I Agree!	Enrollment Agreement/Fee Disclosure Tuition Fees: (fee includes textbook, audio practice CD, and handouts.) Group Classes $295 Private Classes Care & Ashley $550 Laura $450 Makeup Classes Care & Ashley $100 Laura $65 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 instructors 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.
Mother's E-Signature:	Date:
Partner's E-Signature:	Date: