Hypno-Empowered Birth
Registration For:_____________________________________
Address:____________________________________________
____________________________________________________
____________________________________________________
Phone:__________________
Cell:____________________
Work:__________________
Email:________________________________________________
Birth Companion/Father/Partner:________________________
Phone:__________________
Cell:____________________
Work:__________________
Email:________________________________________________
Mom’s Estimated Due Date:____________________________
Care Giver/Doctor/Midwife:____________________________
Care Giver’s Phone:___________________________________
Birthing Facility:______________________________________
Class Start Date:______________________________________
Class Start Time:______________________________________
Copy, Print, and Complete Registration and Send. Or Email it back. Please enclose Registration Reservation of $75 or pay online below
Class Registration Deposit
To hold your place in a class and pay the deposit of $75.00
To Make a Full Payment For a Class
To make full payment for a class that includes all class materials, CD's, handouts and includes your birthing partner.
To Pay the Difference
Other Options
Such as Traveling Upcharge
More Options