Membership form 2019
Please complete the following fields in order to join Multiples Canterbury.
Name: *
Your answer
Address: *
Your answer
Suburb:
Your answer
City: *
Your answer
Postal code: *
Your answer
Phone number:
Your answer
Cellphone number: *
Your answer
Email address: *
Your answer
Type of multiples: *
Estimated due date (40 weeks) of your multiples: *
If they have already been born, please insert their actual birth date.
MM
/
DD
/
YYYY
Partner's name:
Please include contact details, if different to your own
Your answer
Details of additional children:
Please include names, dates of birth, and genders of any additional children (and of your multiples' names, if already known). Tip: Shift+Enter to create a new line for each child.
Your answer
Would you like a buddy? *
New and expectant parents only: this is a current member who would act as a support person and point of contact for you.
What level of membership would you like? *
The appropriate membership fee should be paid directly into the club account: Westpac 03-1702-0024511-00 (include your first name and surname in the reference and particulars fields, to ensure we match payments correctly).
How would you like to pay? *
Privacy: *
I give permission for the Multiples Canterbury to use my personal details for: the membership database; emailed event updates; magazine information (such as welcome to new members and babies, expectant parents and birthday list) and photographs taken at events for publication in the magazine & members only areas of the website. Note your information will otherwise be kept in confidence in accordance with the Privacy Act 1993.
Emails: *
I agree that Multiples Canterbury can email me information about news, new services, and events.
Submit
Never submit passwords through Google Forms.
This form was created inside of Multiples Canterbury. Report Abuse - Terms of Service