Registration Form - GPMOMC

Become a member of the Greater Portland Mothers of Multiples Club and maintain your membership.

Please enter your information below and post payment to our PayPal account.

Name (First and Last)

This is a required question

Are you a new or returning member?

New Member
Returning

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Street Address

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City

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State

ME
Other:

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Zip Code

Please enter a valid zip code

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Phone

Please enter a valid phone number

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Must be a valid email address

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PayPal Username

Please write the name that you use to log into your PayPal account in order to recognize that payment has been received.

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-- CHILDREN --

Please not the names and birth dates of your children.

Child Name (1)

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Child Birth Date (1)

Child Name (2)

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Child Birth Date (2)

Chid Name (3)

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Child Birth Date (3)

Child Name (4)

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Child Birth Date (4)

-- PRIVACY --

Do you agree to have the above information listed in a directory viewable to club members only?

This is a required question

-- SURVEY --

If you checked Hospital and/or Clinic above, please include the name(s) here:

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