2005 fees are:

Date Prospective Member Info Obtained (today’s date):__________

Date Prospective Member Joined As Member:___________

DOUBLE DILEMMA

Prospective Member Form

General Information
^Name		^{Phone Number}	^{Birth Date}
^Address		^{City, State, Zip}
^{Email Address ( Would you like to receive newsletter by email?)}
^{Marital Status:} ^{Single Married Other}	^{Husband’s Name}	^{Husband’s Birth Date}	^{Anniversary Date}
^{Children’s Names}	^{Date of Birth}	^Sex	^{Birth Weight}





^{Twin Type:} ^{Identical Fraternal Unknown}		^{How were your twins conceived? (optional)} ^{Natural Fertility Procedures}
^{Do you work?} ^{Full Time Part-Time Stay At Home Mom}
Club Information
^{How did you hear about our club?}
^{How could our club be of value to you?}
^{Are you interested in any of the following?} ^{Club Meetings Playgroup Mom’s Night Out Newsletter Mom & Tot Outings Group Discussions Clothing Sale}
^{Other Comments?}
ALL INFORMATION IS FOR CLUB USE ONLY

Please return this completed form to either:

Heidi Ellis Heather Tarson

1245 Harvest Court 9901 Bedford Drive

Crystal Lake, IL 60014 Huntley, IL 60142

Ph. 815/455-6860 Ph. 847/961-5474

FOR CLUB USE Prepacket______ Newletter #1______ #2______ #3______ Joined______ New Member Packet_____ Club Notified_______