Renewal Form | Mansfield Mother's Club

Yay, you have chosen to renew! Please fill out our survey and include your information below.

1. Your Information

DATE

NAME*

First Last

ADDRESS*

Street Address City ZIP / Postal Code

EMAIL*

Enter Email Confirm Email

PHONE*

In the coming year, would you like to:

Join the party planning committee
Join the Relay for Life team
Help plan and coordinate service projects
Bring a meal to a club member who is in need of support services or has recently given birth
Bake seasonally for Our Daily Bread, Mansfield's Food Pantry

2. Survey

In the past year, how many events have you attended total?

None
1-3
4-6
6 or more

Are you in a playgroup that meets at least once per month?

Yes
No

If NO would you like to join a playgroup or be connected with an active group?

Yes
No

Please check everything you have particpated in from the list below:

Posted or responded to our Facebook or Meetup groups
Attended a Moms' Night Out and/or Moms' Night In
Attended a family event (e.g. Spring or Halloween parties)
Attended one of our speaker events (e.g. Preschool Fair, Sleep Talk)
Helped with a service project (e.g. donating children's items, baking for Our Daily Bread)
Cooked a Sunshine meal for a new mom or mom in need of support services
Joined our Relay for Life team to support the American Cancer Society

Overall, would you say that the Mothers' Club is meeting your needs?

Yes
No

Please share any ideas or suggestions:

3. Children in Your Household

Please include your children's names and birthdates to help us set up playdates and plan age-appropriate activities for the club. (To add more children, please click the + sign next to the "Birth Date" text field.)

Children*

First Name	Last Name	Birth Date

Would you like your child's birthday announced in the appropriate monthly newsletter?*

Yes
No

4. Liability Release

By clicking below I, the undersigned, understand that my participation and the participation of any members of my family in any Mansfield Mothers’ Club activity or program is completely voluntary, and hereby give permission for me and my family to join in those activities or programs. My family shall hold harmless this local Mansfield Mothers’ Club, the Mansfield Mothers’ Club Corporation, any Mansfield Mothers’ 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 the final responsibility for my safety and the safety of my family rests with me.

Do you accept the conditions in the Liability Release?*

Yes

To weed out spambots, please complete this simple equation.

5. Purchase Your Household Membership

RENEWAL: 1-YEAR HOUSEHOLD MEMBERSHIP

Price: $25.00

Processing Fee

$2.00

Total

$0.00

Comments

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