Renewal Form

1. Your Information

Date *

First Name *

Last Name *

Street Address *

City

ZIP / Postal code

Email Address *

Confirm Email Address *

Phone Number *

In the coming year, would you like to:Join the party planning committeeJoin the Relay for Life teamHelp plan and coordinate service projectsBring a meal to a club member who is in need of support services or has recently given birthBake seasonally for Our Daily Bread, Mansfield's Food Pantry

2. Survey

In the past year, how many events have you attended total?None1-34-66 or more

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

Please check everything you have particpated in from the list below:Posted or responded to our Facebook or Meetup groupsAttended a Moms' Night Out and/or Moms' Night InAttended a family event (e.g. Spring or Halloween parties)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 servicesJoined our Relay for Life team to support the American Cancer Society

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

What has been the best part of the mom's club for you/your family? What would you like to do more of in the coming year? Please also share any ideas or suggestions for ways we can improve our programming!* *

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.

Children

Child 1 First Name

Child 1 Last Name

Child 1 Birth Date

Child 2 First Name

Child 2 Last Name

Child 2 Birth Date

Child 3 First Name

Child 3 Last Name

Child 3 Birth Date

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

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

5. Purchase Your Household Membership

RENEWAL: 1-YEAR HOUSEHOLD MEMBERSHIP

Price: $25.00

Processing Fee

$2.00

Total

$27.00

Mansfield Mothers' Club

1. Your Information

2. Survey

3. Children in Your Household

4. Liability Release

5. Purchase Your Household Membership