Gentle, relaxed birthing..

Janice Weaver-Rex
Peaceful Birthing
810 Plate St. #207, Rochester MI 48307
248-429-9070
yourpeacefulbirthing@gmail.com

the way nature intended

www.YourPeacefulBirthing.com

Course Enrollment
__________________________________________________________________________________
Mothers Name
__________________________________________________________________________________
Mailing Address
_________________________________________ _______________________________________
Preferred phone
Alternate phone
_________________________________________ _______________________________________
Moms email & Birthing Companions 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 for a 5 class series.

TO REGISTER:

$100 non-refundable deposit mailed with Course Enrollment form to the above address, $225 due in Class 1.
Please make checks payable to Janice Weaver-Rex. Mail registration form and deposit to:
Janice Weaver-Rex, 810 Plate St. #207, Rochester, MI 48307

T HANK YOU!

Course Enrollment Agreement

I hereby state that I am enrolling in the 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 , 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.

Mothers Signature

Date

Financial Policy for Peaceful Birthing Classes

Payment:
Peaceful Birthing class tuition structure:
$325 for 5 week series
$375 for accelerated weekend format
$550 for requested private instruction
$45 to teach a private make-up of a missed class
$0 to sit in on another class, if available, for a make-up of a missed class
A $100 non-refundable deposit is required to hold your class space. You are not considered registered for
class until your deposit has been received. The balance of payment is due at the beginning of Class 1.
Cash, checks, money orders or PayPal are accepted.
Refunds: Your deposit is not refundable for any reason. If you pay the entire fee before our 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 repayment directly
from insurance companies.
Private Classes: If your schedule requires individual, personal classes, please inquire about availability.
Private Class tuition is $550.
Refreshers: Current Peaceful Birthing Students: Once you have completed your class series, you are
welcome to sit in on any classes that Peaceful Birthing offers until your due date at no extra charge.
Students who have birthed and previously taken HypnoBirthing with Peaceful Birthing are welcome to attend
any class(es)1-5 at $50 each. Or take the 5 week series in its entirety for $200.