Affiliate Membership Application

2008 - 2009

Name: _______________________________________________________

Mailing Address: _______________________________________________

_______________________________________________

_______________________________________________

(City)                                                                                          (State)                            (Zip Code)

Telephone: (________)________________________ Email: __________________________

Please check one:

Parent of Multiples:________

Grandparent of Multiples: ________

Health Care Provider: ________

Educator: ________

Counselor: ________

Child Care provider: ________

Other (explain): ________________________________________________

Assessment:  Annual dues are $12.00 per individual, which expires each August.

Disclaimer:  No affiliate member may benefit financially from membership or use membership for personal or business gain.

Signature: _______________________________________  Date:____________

Make check payable to: Wisconsin Organization of Mothers of Twins Clubs   or   WOMOTC

Mail this form & payment to:              Diane Baillargeon , Treasurer

Membership & payment to:                 7747 West Allerton Avenue   

                                                  Greenfield, WI   53220

Payment Received from:______________________________________________

Amount: $______________                     Date:_____________________