Membership for Mothers & More Chapter Boston MetroWest #132

New
Renewal
Name: __________________________________________
Address: ________________________________________
City: State: Zip: ___________________________________
Phone number: ___________________________________
Email Address: ___________________________________

Current Employment Status:

Not Employed for pay Employed Part Time Employed Full Time

Current Occupation:
Former Occupation:

Child(ren)’s name(s) and date(s) of Birth:
Child One _____________________________________
Child Two _____________________________________
Child Three ____________________________________
Child Four _____________________________________

Membership Fees

One Year membership $45
Here’s my tax-deductible donation of $ ___ to help with support and advocacy work.
Send a gift membership (additional $45) to the person named below, and let her know it’s from me!
Recipients Name:__________ Address:___________________________
City/State/Zip: _______________________________________________
Phone: __________________

Total Remitted: $_____________

Method of Payment:
Check, made payable to: Mothers and More
Send check to: National Headquarters • P.O. Box 31 • Elmhurst, Illinois 60126**
Go to Web Site and pay by credit card www.mothersandmore.org (click on join in upper right)

If you have any questions, please call Jeannine at 781-721-7827.
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