First Name:
Last Name:
Address:
City:
State:
ZIP Code:
Email Address:
Phone Number:
Your Birthday:
Children's Name(s):
Children's Age(s):
Children's Birthday(s):
Spouse's Name:

What are your interests (personal)

What kinds of activities or events would you like to see the chapter do?

What were your reasons for joining ClubMom and the local chapter?

What are good mommy only days, and would you be willing to host an activity at your house (with or without kids, please specify if without kids is best)?

Specialty areas (scrapbooking, cooking, crafts, etc.)

Memberships (Zoo, Sea World, etc.)

Are you interested in a babysitting co-op or know a reliable babysitter?

General Comments or Questions