MOMS
Club of Orange-Northwest Membership Application
Please complete
and return with your $25 check made payable to the MOMS Club of Orange-Northwest. Send to Stephanie Morones at 1211 Mayfair Ave., Orange, CA 92867. If you have any
questions please call Stephanie at (714) 532-6257. All information marked with an “*” will be included in the
MOMS Club of Orange-Northwest Membership Directory, unless otherwise requested. MOMS Club membership directories are kept
strictly confidential. Only current members are allowed a copy. They are not used to target members with advertising or selling
opportunities.
MEMBERSHIP INFORMATION
* NAME ________________________________________________ *BIRTHDAY _________________
* ADDRESS (include
zip) ____________________________________________________________
* TELEPHONE ____________________________* HUSBAND’S NAME_______________________
*EMAIL ADDRESS_______________________________________________________________________
* CHILDREN’S NAMES AND BIRTHDATES:
_____________________________________________________________________________________
_____________________________________________________________________________________
* ANNUAL PASSES (Disneyland, Knotts, etc.) _________________________________________
HOW DID YOU HEAR ABOUT US? ____________________________________________________
ARE YOU EMPLOYED PART-TIME OR DO VOLUNTEER?__________________________________
IF SO, WHAT DO YOU DO? __________________________________________________________
WOULD YOU BE INTERESTED IN BEING IN A PLAYGROUP? ______________________________
LIABILITY RELEASE
I,
the undersigned, understand that the participation of myself and/or any member of my family, in any MOMS club function or
program is completely voluntary, and we hereby give permission for myself and my family to join in those functions or programs.
My family shall hold harmless the MOMS Club of Orange-Northwest, the MOMS Club Corporation, any MOMS Club volunteers or representatives,
and/or the providers of any function’s or program’s location and/or materials from any liability and/or responsibility
for any accident, illness, injury that occurs during or as a results of any function or program. I accept that the final responsibility
for my safety and that of my family rests with me.
DATE:
______________________ SIGNATURE: ___________________________________________
