Peninsula Mothers of Multiples

Membership Form

 

 

 

Please Circle:                                           RENEWAL                                              NEW MEMBER

 

Date:       ______________________________Join Date(Renewals):__________________________________________________________

 

Name:    _________________________________________________Spouse:      ________________________________________________

 

Address:________________________________________________Phone: home___________________cell__________________________

 

                ________________________________________________E-Mail         ________________________________________________

 

Your Birthday_____mo______day      Spouse’s Birthday______mo______day     Anniversary______mo______day

 

If you are expecting, please write your approximate due date:_________________________________________________________________

Children’s Names (include singletons)	Birthday: m/d/yr	Gender	Multiple Type(Identical/Fraternal)

 

PMOM has a monthly newsletter, The Multi Media. In order to defray club costs we would prefer to send this newsletter electronically. ______Yes, please send my newsletter via e-mail ______No, please send via USPS

 

PMOM has an internet chat forum where you are free to post questions to the group, answer questions, and view files, post ideas etc. Please note that you will receive additional e-mail to your inbox, unless you request only to view the posts at the forum address. ____yes, invite me _____No, I prefer to think it over, requesting the option later

 

Occassionally, photos may be taken of yourself or members of your family. Please authorize the release of your pictures (without names) for advertising purposes online at our website and in the news media with your signature:

 

_________________________________________

 

PMOM hosts several fundraisers throughout the year. The simplest if the Food Lion Shop and Share where each time your MVP card is scanned a percentage of what you have spent will go to the organization of your choice. Please provide you 12 digit MVP number to help support PMOM:

                                                                                                ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___ ___

PMOM is a support network of moms. We can help each other by sharing experiences, advice, and tips. Please indicate which areas you are able to help members with. This information will be made available to our members at large.

	Amniocentesis/Chorionic Villus Sampling		Stay at Home Mom
	Bedrest		Triplets/Higher Order Mults
	Gestational Diabetes		Asthma/Allergies
	C-Section		Creating a Schedule
	Vaginal Delivery		Post Partum Depression
	NICU		Potty Training
	Apnea Monitors/O2		Medical Problems Specify:
	Breastfeeding		Learning Disabilities/Delay Specify:
	Weaning		Physical Handicap Specify:
	Bottle Feeding		Child Care/Nannie
	Returning to Work		Other:

 

Big Sister/Little Sister: As a mom of multiples 12 months or older the club would like to have your help! You can be paired as a Big Sister to another mom. You would agree to contact the new or expectant mom at least once a month by phone and/or e-mail.

 

_____Yes, I would like to be a Big Sister

 

 

 

I/My Family has a business (ie. Family owned, service industry, independent sales: Mary Kay etc. babysitting, odd jobs, etc.). I would  like our  business listed in the PMOM Resource Directory.

 

Company Name______________________________________________________________________________

 

Product/Service______________________________________________________________________________

 

Contact Info: (Address, Phone, e-mail, web address)_________________________________________________

 

I heard about PMOM from:_____________________________________________________________________

 

PMOM is co-sponsored by Riverside Regional Medical Center, Mary Immaculate Hospital and Sentara Careplex. We provide goody bags to all moms of multiples who have delivered their babies in either of these facilities. Did you receive a goody bag from the hospital staff.  _____Yes  _____No

 

What are your hobbies?__________________________________________________________________________

 

Would you use a bumper/window sticker on your vehicle advertising our club if it came in your club packet?______

 

Would you be interested in a club  embroidered t-shirt?_________________________________________________

 

What outside functions are you interested in? (apart from monthly meetings) Circle those that apply:

 

Playgroup              Mom’s Night Out (not  separate from meeting nights)                  Family Functions (ie. Picnics)

 

 

Scrapbooking       Craft Theme nights                                                                              Other:

 

 

Dues: Membership dues are $25 annually which include both local and national membership.

Please make checks  payable to PMOM and remit to the membership representative before leaving tonight’s meeting  or mail to:

                                               

                                                PMOM

PO Box 1024

Newport News Va 23601

 

 

We welcome you to PMOM!

 

 

 

Date Paid_____/_____/_____         Cash/Check #_____            Name Tag Issued _____/_____/_____

Revised August 2006 PF