Membership Form

Tri-County Mothers of Twins Club

Membership Form

Choose One:

_____ Renewing Member (only fill out Part I unless updates are needed in Part II)

_____ New Member (fill out Parts I and II)

Annual Dues are $10 and are due in September.

New members may join at any point in the year.

Please make checks payable to : Tri-County MOTC and mail this form to :

Laurie Gregorek

146 Hayes Road

Schuylerville, NY 12871

Part I

Name_____________________________

Street Address__________________________________________

City____________________________  State _____  Zip ___________

Home Phone_____________________  Cell Phone ____________________

Part II

***Birthdates and anniversary dates will only be used for recognition in the newsletter***

E-mail (newsletters/correspondence will be sent to this address)_________________________________________

Member's date of birth _____________

Spouse's name_______________________  Date of birth ____________________

Anniversary date _________________________

Children's names                                                   Date of birth

________________________________         ____________

________________________________         ____________

________________________________         ____________

________________________________         ____________

________________________________         ____________