PRIVATE HYPNOBIRTHING COURSE ENROLMENT FORM
Please fill in the form below. I will contact you asap to confirm enrolment.
Mother's name
*
First Name
Last Name
Birth partner's name
First Name
Last Name
E-mail
*
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State
Post code
Estimated Due Date
-
Day
-
Month
Year
Date Picker Icon
Program Type
Hypnobirthing PRIVATE Course - ($925)
Hypnobirthing REFRESHER - ($290)
Positive CAESAREAN Course - ($395)
Hypnobirthing INTENSIVE Course - ($660)
Care provider name:
Eg Midwife/Doctor/Obstetrician
Location/hospital:
Do you have private health insurance? If so, please specify your private health fund
Is this your 1st, 2nd, 3rd etc baby?
Preference for class time/day
Eg weekday, weekend or evenings. Do you have a preferred date?
Is there any important information you need me to be aware of before classes commence?
Eg previous pregnancies, medical or emotional health concerns.
Additional information
Do you have any questions about the program? Please leave them here and Rosie will be in touch asap.
Payment details
To hold your place, a $150 non-refundable tuition deposit is requested. Final payment is due 7 days prior to course start date. Payment can be made by cash, direct deposit or PayPal.
Direct Deposit : Rosie Fitzclarence BSB: 063551 Acc. 10148447 PayPal : rosie@geelongborn.com.au (debit or credit card).
SUBMIT FORM
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