Course Enrollment and Release Agreements

Name(required)

Pronouns (He/She/They, etc.)

Email(required)

Mailing Address (required)

City, Zipcode(required)

Phone Number(required)

How did you hear about this class?

If you are attending the HypnoBirthing® Classes for parents:

Birthing Companion's Name

Pronouns (He/She/They, etc.)

When is your baby expected?

What would your like your baby to call you?

I hereby state that I am enrolling in the HypnoBirthing® Class and/or workshop 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 my 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 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. YES or NO(required)

I grant permission to HypnoBirthing® International and its affiliate Portland HypnoBirthing® Center, to use photographs/and or video and audio taken of me. The images/video/audio/may be used for educational, teaching and promotional purposes only. I authorize HypnoBirthing® International and its affiliate Portland HypnoBirthing® Center to copyright, use and publish the same in print, video, and/or electronically. All educators given access to the images/video/audio have signed an agreement stating the above, and ensuring that no unauthorized content is uploaded to the internet or reproduced. I indemnify HypnoBirthing® International from any and all liability arising out of the use of the images/video/audio and waive any and all claims and causes of action relating to the use of the images/video/audio and waive any and all claims and causes of action relating to the use of the images/video/audio, including without limitation, claims for invasion of privacy rights or publicity. I am 18 years of age or older, am the parent of legal guardian of the minor in the images/video/audio. I have read this release before checking this box, fully understanding the contents, meaning, and impact of this release. YES or NO(required)

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