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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.
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* Required
Name (First and Last)
*
Your answer
Are you a new or returning member?
*
New Member
Returning
Street Address
*
Your answer
City
*
Your answer
State
*
ME
Other:
Zip Code
*
Your answer
Phone
*
Your answer
Email
*
Your answer
PayPal Username
*
Please write the name that you use to log into your PayPal account in order to recognize that payment has been received.
Your answer
-- CHILDREN --
Please not the names and birth dates of your children.
Child Name (1)
*
Your answer
Child Birth Date (1)
*
MM
/
DD
/
YYYY
Child Name (2)
*
Your answer
Child Birth Date (2)
*
MM
/
DD
/
YYYY
Chid Name (3)
Your answer
Child Birth Date (3)
MM
/
DD
/
YYYY
Child Name (4)
Your answer
Child Birth Date (4)
MM
/
DD
/
YYYY
-- PRIVACY --
Do you agree to have the above information listed in a directory viewable to club members only?
*
Yes
No
-- SURVEY --
How did you find out about GPMOMC?
Website
Hospital
Clinic
Friend / Member
Other:
If you checked Hospital and/or Clinic above, please include the name(s) here:
Your answer
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