Date_________________

 

Name _______________________________Husband/Partner’s Name __________________

 

Address ____________________________________________________________________

 

City _________________            Zip ___________            Phone Number __________________

 

Your Birth Date _________________________ Email Address: _________________________

 

Child(ren)’s names, birth dates and gender:

 

_________________________________________

 

__________________________________________

 

__________________________________________

 

How would you prefer to receive the monthly chapter newsletter (please check one)?

e-mail _____      U.S. mail _____

 

May we publish your name, phone number, child(ren), and their ages in the New Member section of our Newsletter?     Yes ____   No ____

 

May we include your name, address, email, and phone number in our “published” membership list?  “Published” membership lists are for member use only and are published periodically in our newsletter and on our web site (the membership list on the web site is password protected to members only).   Yes ____   No____

 

Former career/position:_______________________________________________________________

 

Current employment outside the home:__________________________________________________

 

Major hobbies and/or interests:_________________________________________________________

 

Are you interested in participating in a playgroup with your child(ren)?   Yes ____    No ____

 

Are you interested in participating on our Board or in any of our committees?  Check any that are of interest to you and you may be contacted by another member when that committee needs help.

___  Co-Leader ___  Advocacy ___  Care (coordinating meals, childcare, etc. for members in need) ___  Charitable

___  Fundraising ___  Membership ___  Newsletter ___  Play Group ___  Programming (plan meeting topics & schedule speakers)

___   Publicity ___   Secretary ___   Social ___   Treasurer ___   Welcome ___ Webmaster

 

How did you hear about Mothers and More?  (check all that apply) 

__Friend/Neighbor   __A2 Observer   __Metro Parent Magazine   __The A2 News  __ Newcomer’s

__Other publication (please list) ____________ ___ other source _______

 

Please return this form with your membership application and annual dues of $45 to

Denise Brendel, Membership Coordinator, 7235 Muirfield Dr., Ypsilanti, MI   48197.

Please make checks for $45 payable to Mothers and More.