South Loop Mom-n-Tots by 7LiH18j


									                                     Grande Park Moms Group
                 Membership Information and Liability Release

Mom’s Name:

Date of Birth:                                  Email:

Home Address:

City:                                      State:   ZIP:
Home Phone:                                Cell Phone:
                             Spouse Information
Name and Phone #:
                        Child’s/Children’s Information
Name:                                         Ages:  DOB:

                                  About You
Are you expecting?                      If so, when is your due date?
What are some of your hobbies or special        What activities would you like to
interests:                                      participate in/help organize:

What times/days are you available to            Do you work or volunteer outside
participate in activities:                      of the home? If so, what do you

                                       Grande Park Moms Group
              Membership Information and Liability Release
Does your child have any known allergies?

I, the undersigned, understand that my participation and the participation of any member(s) of
my family in any Grande Park Moms group activity or program is completely voluntary, and I
hereby give permission for me and my family to join in those activities or programs.

My family shall hold harmless the Grande Park Moms group and any Grande Park Moms group
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 that the final responsibility for my safety and that of my family rests with me.

Signature of Applicant:                                                    Date: ____________

Mail this form (sorry cannot be emailed) and the $25                         2006/2007
                                                                             Board of Directors
annual membership fee to:
Nikki Svejda 12818 Grande Poplar Cir. Plainfield, IL 60585                   Presidents:
                                                                             Shelly Heckman
Please make your check payable to “GPMNT”.
                                                                             Vice President:
                                                                             Nikki Svejda
If you have any questions or suggestions, please contact                     815-267-8801
one of our board members listed to the right.                                Treasurer:
                                                                             Kristin Emmert
We look forward to meeting you and your tots very soon!!
                                                                             Shannon Reinighaus

                                                                             Sunshine Committee:
                                                                             Judy Lee Johnson


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