MOMS Club of Derry, NH Membership Application & Liability Release Form
ALL MEMBERS MUST HAVE A SIGNED MEMBERSHP AND LIABILITY RELEASE FORM ON FILE WITH THE MOMS CLUB OF DERRY, NH BEFORE ATTENDING ANY ACTIVITIES OR PROGRAMS.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
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Moldova
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
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Palau
Palestine
Panama
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Paraguay
Peru
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
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Slovenia
Solomon Islands
Somalia
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South Ossetia
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Sudan
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
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Ukraine
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United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Birthday
E-mail
Home Number
-
Area Code
Phone Number
Cellular Number
-
Area Code
Phone Number
Child's Name
Child's Birthdate
Child's Name
Child's Birthdate
Child's Name
Child's Birthdate
Do you have any pets? If so, what type?
Cat
Dog
Ferret
Hampster
Rat
Reptile
Horse
Guinea Pig
Other
Do you or your child(ren) have allergies and if so, what kind?
No
Other
How did you hear about us?
MeetUp
Facebook
MOMS Club International
Friend
Library
Derryfest
Google Search
Other
Please check off if you are interested in more information on any of these following activities:
Playgroup
Walking Club
Book Club
Stitcher's Club
Cooking Club
Craft Club
Other
Emergency Contact 1
Phone Number
Emergency Contact 2
Phone Number
I, the undersigned, understand that photographs, audio recordings, or videos may be taken during any MOMS Club activity. By checking below, I agree that any photographs, images or likenesses of me and or my family may be used for MOMS Club purposes such as, but not limited to MOMS Club newsletters, scrapbooks, future publicity materials, and social media including but not limited to Facebook and MeetUp as well as chapter and corporate website. Photographs and names may also be published in the local newspapers.
YES, I give my consent to use my family's images
NO, consent is not given to use my family's images
This information may be included in the group roster or newsletter. It will also help us plan future activities. If you have an idea for the group, please discuss it with a member of the Executive Board.
I, the undersigned, have received a copy of the Code of Conduct for The MOMS Club of Derry, NH and agree to abide by these rules of conduct and behavior.
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 me and my family to join in the 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 responsiblity 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.
Signature
Signature date
Membership dues of $25.00 paid via:
Please Select
Cash at Business Meeting
Check at Business Meeting
Please send invoice and link for credit/debit card payment
Form Type
Please Select
New Member
Renewal
Update Information
Apply for Membership
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