Janice Rex Weaver

Peaceful Birthing Certified HypnoBirthing Practitioner

Gentle, relaxed birthing….. 3795 Delano Rd., Oxford, MI 48370
the way nature intended
607-329-5744
www.YourPeacefulBirthing.com yourpeacefulbirthing@gmail.com

Course Enrollment
__________________________________________________________________________________
Mother’s Name

__________________________________________________________________________________
Mailing Address

_________________________________________ _______________________________________
Preferred phone Alternate phone

_________________________________________
Preferred email

_________________________________________________________________________________
Birthing Companion (spouse, partner, etc.) Relationship

_________________________________________ _______________________________________
Birthing Assistant Relationship (doula, friend, etc.)

_________________________________________ _______________________________________
Care Provider Name & Title City

_________________________________________ _______________________________________
Birthing Facility City

_________________________________________ ______________________________________
When is baby expected? How many weeks pregnant will you be when
you begin classes?

I wish to enroll for the class beginning (date):_____________ Location: ____________________

Where did you hear about Peaceful Birthing?: __________________________________________

First Baby?_______ If not, how many children and how were your other birthing experiences?

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Tuition is $325. ($100 non refundable deposit mailed with Course Enrollment form to above address, $225
payable to Janice Rex Weaver when class starts). Please be in touch if you prefer to use a credit card. Class
tuition includes textbook, audio practice CD’s, handouts, phone and email consults.
THANK YOU! I look forward to sharing classes with you.
Financial Policy for Peaceful Birthing Classes

Payment: The fee for classes is $325. A $100 non-refundable deposit is required to hold
your place in class. You are not considered registered for class until your deposit has been
received. The balance of payment is due at the beginning of Class One. After deposit has
been paid, $45 weekly payments are available if helpful. Cash, checks, money orders or
PayPal are accepted. I am able to directly accept credit card payments for classes at the
Mental Fitness Center in Rochester only.

Referral:
Referral If you refer a friend to the same series that you are enrolling in, you will receive a
$25 discount on your class fee.

Refunds Your deposit is not refundable for any reason. If you pay the entire fee before our
Refunds:
class series begins, and must cancel, your fee will be refunded minus the $100 deposit.
Once the classes have begun, I am unable to offer refunds if you are unable to complete the
class series.

Insurance: A receipt will be issued upon receipt of full payment if requested. You may submit
this receipt to your insurance company for reimbursement, if your carrier provides such. I do
not accept assignment from insurance companies.

Private Classes: If your schedule requires individual classes, please inquire about
availability. Private Class tuition is $385.

Refreshers Current Students: Once you have completed your class series, you are welcome
Refreshers:
to sit in on any classes that I offer until your due date at no charge. Students who have
previously taken HypnoBirthing classes with me are welcome to attend any or all classes 1-5
at $35 each.
Enrollment Agreement

The HypnoBirthing Institute may contact you for quality assurance and research
purposes. If you consent to be contacted now, please note that you are free to change
your mind at any time. Be assured that we will not share your personal identifying
information with anyone outside the HypnoBirthing Institute for any purpose. Thank
you for your help in collecting data to support the growth of HypnoBirthing ®.

I do ______ I do not _______ agree to be contacted by the HypnoBirthing® Institute.

I hereby state that I am enrolling in the HypnoBirthing

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 instructor of the HypnoBirthing
HypnoBirthing classes, or the
HypnoBirthing Institute
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 Signature Date