Step 1 of 3 33% Mother's Name* First Last Birthing Companion Name*Mailing Address* Street Address City State / Province / Region ZIP / Postal Code Preferred Phone*Preferred Email* Care Provider Name & Title (e.g. Obstetrician)*Hospital / Birthing Facility*When is baby expected?* Date Format: DD slash MM slash YYYY How many weeks pregnant will you be when you begin classes?*What number baby is this ?*Please enter a number from 1 to 3.1 2 3Is this birth a VBAC or is there any important information/medical conditions/psychological or psychiatric treatment you need me to be aware of before classes commence?* I wish to enrol for the Hypnobirthing Course beginning:* Date Format: DD slash MM slash YYYY Location:*Where did you hear about My Private Midwife?*ENROL AND PAY NOW: To hold your place and receive your text and CD prior to the first class please submit this completed form with the non-refundable tuition deposit.*HYPNOBIRTHING PRIVATE CLASSESHYPNOBIRTHING GROUP CLASSESHYPNOBIRTHING 1/2 online 1/2 group1/2 Online 1/2 Private 6 hour sessionHypnobirthing ONLINE and one sessionREFRESHER CLASSDEPOSIT ONLY - $150.00FACE TO FACE CONSULTEARLY PREGNANCY CLASSPOSTNATAL PACKAGEIf choosing 'DEPOSIT ONLY' , final payment is due 14 days prior to course start date. When you submit your form details you will be taken to Paypal to make your payment. ***Deposit is non refundable as per cancellation policy****Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name Total $ 0.00 PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
