Membership Application Form
MOMS Club of Eugene Membership Application, Liability Release, Sick Policy and Code of Conduct Agreements
Application Form
Member's First and Last Name *
Your answer
Birth Date *
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Spouse/Parter
Your answer
Address *
Your answer
Phone Number *
Your answer
Do you have a Gmail account?
We use Google Calendar for our MOMS Club event calendar, so if you have a gmail address, please list it below for calendar access. If you don't have a gmail account, don't worry, we have one you can use instead.

If you want MOMS Club emails to go to an email account other than gmail, please list that email address as well, and you can receive all MOMS Club emails to that account. Gmail is just used to give you access to our private calendar.
E-mail Address(es) *
Your answer
Children's Names, Birthdates, and Gender *
Your answer
Caregiver Type
Have you been a member of this MOMS Club, or any other MOMS Club? If so, which chapter, and when? *
Your answer
How did you hear about us? *
Your answer
What are your hobbies and special interests? *
Your answer
Do you work or volunteer? If so, what do you do? *
Your answer
Are you interested in serving on the MOMS Club board? *
Liability Release
The information above may be included in our club roster and/or newsletter. I, the undersigned, understand that my participation and the participation of any members of my family in any MOMS Club activity or program are completely voluntary, and we hereby give permission for me 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 representatives, paid or unpaid, and/or the providers of any activity or program location and/or materials from any liability and/or responsibility for any accident, illness, or injury that occurs during or as a result of any function or program. I accept that the final responsibility for my safety and that of my family rests with me.
Disclaimer: *
Required
Printed Name Signifying Acceptance of the Liability Release *
Your answer
Date Signed: *
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Sick Policy
Please keep your child home if they have experienced any of the following symptoms within 24 hours prior to attending any MOMS Club® function:

- Diarrhea
- Earache
- Fever of 100 or higher (children should stay home until their body temperature has remained normal for 24 hours)
- Green or yellow nasal discharge
- Heavy cough/croup
- Pinkish appearance of eye, especially with discharge
- Sore throat/swollen glands
- Unexplained rash/Poison Oak
- Vomiting or Nausea
- Exhibit any symptoms of childhood communicable diseases such as, but not limited to, chicken pox, measles, mumps, lice, 5th disease or hand-foot and mouth disease or whooping cough.

Please contact the President if your child has contracted a communicable disease. Thank you for helping to keep our infants, children and mothers safe.
Do you agree to abide by our sick policy? *
Children's Code of Conduct
MOMS Club® activities are meant to be enjoyable and safe events for both parents and children. The MOMS Club® respects parenting differences but expects that all children behave appropriately at MOMS Club® activities.

Unacceptable behaviors include, but are not limited to:
· Hitting
· Scratching
· Kicking
· Biting
· Spitting
· Slapping
· Hitting with objects
· Hair pulling
· Destroying or being disrespectful of property
· Inappropriate touch
· Overly aggressive behavior

In the unfortunate event that these behaviors occur during MOMS Club® activities, then the child's mother should temporarily remove the child until the behavior has been corrected. If this does not occur, a member may be asked to temporarily remove their child until the behavior has been corrected. This may be done at the discretion of the Executive Board. Resuming activities will also be at the discretion of the Executive Board. This Policy is in place to ensure the enjoyment and safety of club members and their children.
Do you agree to abide by the children's code of conduct? *
Member's Code of Conduct
MOMS Club® is here to support mothers who choose to stay at home with their children. We support all mothers and recognize that there are many different parenting styles and personalities in our Club.

To ensure a safe, supportive atmosphere, we ask the following of all members:
*You are responsible for your children at all MOMS Club® functions. If you cannot supervise them all, please talk to other members ahead of the event to see if they can lend a hand, or bring a relative or other helper (babysitter) to assist you.
*When disciplining your children, please speak in a reasonable voice or remove the children from the area. Loud voices and yelling are upsetting to other children and are disruptive. Please remove your children from the area for time-outs.
*Do not discipline another mom's children without their permission. In the event that your child is in conflict with another child, please separate them and take the other child to his/her mother.
*As a support group, there will be many conversations with and about members. To be supportive, no negative gossip or demeaning comments are allowed. Please also respect the privacy of members who do not have an outgoing nature.
*You are responsible for reading and following the by-laws of this club at MOMS Club® activities, including the general by-laws, the Children's Behavior Policy and this policy.
*To ensure the comfort of moms from all economic and cultural backgrounds, we ask that all members follow the above guidelines. In the unfortunate event that these guidelines are not followed, the Executive Board will discuss the issue with the member(s) involved. The end result may be the member losing membership in the MOMS Club® and forfeiting her dues.
Do you agree to abide by the member's code of conduct? *
ALL MEMBERS MUST HAVE A SIGNED MEMBERSHIP APPLICATION AND LIABILITY RELEASE FORM ON FILE WITH THE MOMS CLUB OF EUGENE, BEFORE ATTENDING ANY ACTIVITIES. It is also expected that all members read and understand the Sick Policy, Code of Conduct for Children, Code of Conduct for Moms, and International Bylaws.

RENEWING MEMBERS ARE REQUIRED TO COMPLETE A NEW LIABILITY RELEASE FORM EACH YEAR AS WELL.

PLEASE COMPLETE THIS FORM AND SUBMIT YOUR ANNUAL MEMBERSHIP DUES. PAYMENTS MAY BE MADE ONLINE WITH A $1.78 PROCESSING FEE, OR ALTERNATIVELY, YOU CAN SEND A CHECK FOR $30.00 MADE PAYABLE TO MOMS CLUB OF EUGENE, OR.

PLEASE SEND CHECK TO-
MOMS Club of Eugene, Oregon c/o Jen Hill, 90375 Shore Lane Eugene, Oregon 97402 (707) 978-8142
Release for Use of Photograph/Videotape/Website/Social Media
Member's Printed Name Signifying Acceptance of the Above Policies: *
Your answer
Date: *
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