Professional Documents
Culture Documents
Course Enrollment
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Mother’s Name
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Mailing Address
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Preferred phone Alternate phone
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Preferred email
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Birthing Companion (spouse, partner, etc.) Relationship
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Birthing Assistant Relationship (doula, friend, etc.)
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Care Provider Name & Title City
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Birthing Facility City
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When is baby expected? How many weeks pregnant will you be when
you begin classes?
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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 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.