MOMS Club of Pelham Area ® Membership Information and Liability Release

ALL MEMBERS MUST HAVE A SIGNED MEMBERSHIP INFORMATION AND LIABILITY

RELEASE ON FILE WITH THE LOCAL MOMS CLUB BEFORE ATTENDING ANY
ACTIVITIES OR PROGRAMS

NEW MEMBER FORM

NAME: DATE OF BIRTH:

ADDRESS:

TELEPHONE: E-MAIL:

HUSBAND’S NAME: FORMER PROFESSION:

CHILDREN’S NAMES, BIRTHDATES, AND KNOWN ALLERGIES:

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IS YOUR CHILD UP TO DATE ON IMMUNIZATIONS? YES OR NO

HAVE YOU EVER BEEN A MEMBER OF THIS OR ANY OTHER LOCAL MOMS CLUB? IF SO, WHICH CHAPTER AND
WHEN?

DO YOU WORK PART-TIME OR VOLUNTEER? IF SO, WHAT DO YOU DO? ________________________________________

WHAT ARE YOUR HOBBIES OR SPECIAL INTERESTS?

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HOW DID YOU HEAR ABOUT US?

PLEASE CHECK IF YOU ARE INTERESTED IN MORE INFORMATION ON ANY OF THE FOLLOWING ACTIVITIES:

_____ Playgroups _____ Volunteering _____ Gardening Club

_____ Cooking Club _____ Book Club _____ Scrapbooking Club

Any other ideas or things you would like to see the club do? __________________________________________________________

THIS INFORMATION MAY BE INCLUDED IN THE GROUP ROSTER OR NEWSLETTER. IT WILL ALSO HELP US PLAN FUTURE
ACTIVITES. IF YOU HAVE AN IDEA FOR THE GROUP, PLEASE DISCUSS IT WITH A MEMBER OF THE EXECUTIVE BOARD!

I, THE UNDERSIGNED, UNDERSTAND THAT MY PARTICIPATION AND THE PARTICIPATION OF ANY MEMBERS OF MY FAMILY IN
ANY MOMS CLUB ACTIVITY OR PROGRAM IS COMPLETELY VOLUNTARY, AND WE HEREBY GIVE PERMISSION FOR ME AND MY
FAMILY TO JOIN IN THOSE ACTIVITIES OR PROGRAMS. MY FAMILY SHALL HOLD HARMLESS THIS LOCAL MOMS CLUB, THE
MOMS CLUB CORPORATION, ANY MOMS CLUB VOLUNTEERS OR REPRESENTATIVES, PAID OR UNPAID, AND/OR THE
PROVIDERS OF ANY ACTIVITY OR PROGRAM LOCATION AND/OR MATERIALS FROM ANY LIABILITY AND/OR RESPONSIBLILITY
FOR ANY ACCIDENT, ILLNESS OR INJURY THAT OCCURS DURING OR AS A RESULT OF ANY FUNCTION OR PROGRAM. I ACCEPT
THAT THE FINAL RESPONSIBILITY FOR MY SAFETY AND THAT OF MY FAMILY RESTS WITH ME.

PHOTOGRAPHS, AUDIO RECORDINGS OR VIDEOS MAY BE TAKEN DURING ANY MOMS CLUB ACTIVITY AND USED FOR MOMS
CLUB NEWSLETTERS OR CLUB DISTRIBUTION. A MEMBER MAY REFUSE THEIR CHILD (REN) IS PHOTOGRAPHED EITHER
VERBALLY OR IN WRITING TO A BOARD MEMBER.

$25 Annual Membership Dues – Payable to MOMS Club of Pelham Area

Mail check and application to MOMS Club of Pelham Area, PO Box 462, Pelham, NH 03076

DATE _______________________________ MEMBER’S SIGNATURE ________________________________________