4AM Mom Club Application
This form is required for approval into the 4AM Mom Club.
Learn more about the 4AM Mom Club at
Sign in to Google
to save your progress.
Name (First and Last please)
Home Address (Full mailing address - street, city, state, zip, everything. We will not be showing up but we may want to mail you a goodie.)
Can you verify that you are a mother or guardian to a child/ren with or that had medical complexities or special needs?
Does your child currently have a diagnosis?
If your child has a diagnosis, please explain below or write N/A.
We want to connect you with other moms. As our community grows we will have smaller tribes available to allow you to connect with others who are similar to you. In what broad categories would you be interested in connecting with other moms? Please add to 'other' to specifically pertain to you.
No known Diagnosis
Children who have passed away
Children with cancer
Mental Health Disorders
Congenital Heart Defect
TERMS AND CONDITIONS:
1. Be kind and courteous. If you insult someone or make them feel unwelcome or unsafe, you will be removed from the group.
2. Do not compare. Each one of us has a unique path we are on. Comparing lives, children or our paths does nothing but rob us of compassion and empathy.
3. Agree to disagree. We know it’s impossible to fully understand the scope of one’s experience through a few online posts, so we give each other grace and the benefit of the doubt. If you disagree, just move along.
4. Respect Everyone's Privacy. Being part of this group requires mutual trust. Authentic, expressive discussions make groups great, but may also be sensitive and private. What's shared in the group should stay in the group.
5. We don’t hand out advice unless it is directly asked for. We already have plenty of people telling us what we should or shouldn’t do. Unless someone specifically asks for advice, we ask that you are a supportive listener unless a member asks for advice directly.
6. No soliciting. This is a no pressure, supportive group. Compassion in any and all forms is welcome. No Promotions or Spam Self-promotion, spam and irrelevant links aren't allowed.
7. No Hate Speech or Bullying. Make sure everyone feels safe. Bullying of any kind isn't allowed, and degrading comments about things like race, religion, culture, sexual orientation, gender or identity will not be tolerated.
8. Remember you have a choice. Remember it is your choice to be here. We will not agree 100% of the time, but we have a choice to be respectful, supportive, compassionate and empathetic or continue on keeping our thoughts to ourselves. This community is for all of us, built by all of us. We need support and respite from the challenging days we walk through. Let’s keep this community strong and supportive…in the same way we have learned to show up for our kids.
IF ANY OF THESE RULES ARE BROKEN YOU MAY BE ASKED TO LEAVE WITHOUT PRIOR NOTICE.
Do you agree with the 4AM Mom Club Terms & Conditions?
YES, I HAVE READ ALL OF THE ABOVE AND AGREE
The 4AM Mom Club is a hosted by When Autumn Comes Podcast. The fee to join the club is $20. However, you can offer more in order to support another moms who may not have the means to cover the fee (because as we all know, special needs and medical parenting is expensive).
These fees are used to provide and reduce the cost of some programming for the 4AM Mom Club members. Additionally, as funding allows, the 4AM Mom Club will assist Mothers around the country who may need help with bills, toys or other needs for their families.
No mom is ever turned away because she can't pay this fee. Please email
to inquire about assistance.
You will receive a PayPal invoice at the email address you listed above.
I would like my donation to:
Cover Myself ($20)
Cover myself and one other mother ($50)
Cover myself and two other mothers ($75)
Cover myself and three other mothers ($100)
Chat about assistance in joining.
Other - I have a Referral / Promo code (see below)
Pay What You Can Option (No worries if you cannot afford the full $20. We get it, this life is crazy. Feel free to pay what you can. Please click this AND the other option, adding what you want to pay in the OTHER line.)
Do you have a Referral / Promo code for joining the 4AM Mom Club? If so, write it here:
Is there anything else you want to tell us?
Do you agree to receive emails from us?
Yes, I agree to receive emails
No, I do not agree
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service