Membership Information & Liability Form
MOMS Club® of Los Feliz, California
First Name *
Your answer
Last Name *
Your answer
E-mail Address *
Your answer
Street Address *
Your answer
Zip Code *
Your answer
Phone *
Your answer
Children's Name(s)(listed in birth order) *
Your answer
Child #1 Birthday *
MM
/
DD
/
YYYY
Child #2 Birthday
MM
/
DD
/
YYYY
Child #3 Birthday
MM
/
DD
/
YYYY
Spouse/Partner's Name
Your answer
How did you hear about us?
Your answer
Have you ever been a member of another MOMS Club® organization?
If so, which chapter and when?
Your answer
Agreement: 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 MYSELF 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 REPRESENTATIVE, PAID OR UNPAID, AND/OR THE PROVIDERS OF ANY ACTIVITY OR PROGRAM LOCATION AND/OR MATERIALS FROM ANY LIABILITY AND/OR RESPONSIBLITY FOR ANY ACCIDENT, ILLNESS OR INJURY THAT OCCURS DURING OR AS A RESULT OF ANY FUNCTION OR PROGRAM. I ACCEPT THAT THE FINAL RESPONSIBLITY FOR MY SAFETY AND THAT OF MY FAMILY RESTS WITH ME. *
E-Signature (Please Type Full Name)
Your answer
I understand the above typed e-signature acts as my signature and is legally binding. *
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