| First Name: |
|
| Last Name: |
|
| Address Street 1: |
|
| Address Street 2: |
|
| City: |
|
| Zip Code: |
(5 digits) |
| State: |
|
| Home Phone: |
|
| Cell Phone: |
|
| Email: |
|
| Birthday day and month (no year): |
|
Can we include this information
in the Club's Directory? |
YesNo |
| How did you hear about the Club? |
|
| Children: |
Boy Girl Birthday:
Name:
Boy Girl Birthday:
Name:
Boy Girl Birthday:
Name:
Boy Girl Birthday:
Name:
|
| Employment: |
Stay At Home Mom
Work Part Time
Work Full Time
Employer: |
| Husband's Profession: |
|
| Husband's Employer: |
|
| Hobbies/Interests: |
|
On a scale of 1-4,
(1 = most important),
please tell us which
events/activities would
be most interesting for you: |
Events for yourself
Events for you and your children
Events for you and your husband
Events for your entire family |
|
Please list any personal or
professional contacts you may
have with local/regional businesses
(name of company or business):
|
|
Since our group does events to
benefit local charities, please tell
us the names of any local/regional
charities you would like us to
consider supporting: |
|
What night of the week works
best for you to attend a quarterly
meeting with the group?
What start time works best? |
|
|
