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Membership Information
Name ______________________________________________Date______________
Address ______________________________________________________________
E-Mail ______________________________________________________________
Phone ________________________________Occupation______________________
Employer _____________________________Work Phone_____________________
If you are a Stay-At-Home Mom now, what was your former occupation?
_____________________________________________________________________
Husband / Father’s Name________________________________________________
Husband / Father’s Occupation & Employer_________________________________
Multiples Names & Birthdays, or if expecting, when are you due?
_____________________________________________________________________
Other Children’s Names & Birthdays_______________________________________
Are your multiples identical / fraternal/ unknown?_____________________________
Special Information about your multiples and family___________________________
_____________________________________________________________________
_____________________________________________________________________
Let us celebrate your special days with you and your family. Please list:
Your Birthday_________________________________________________________
Husband / Father’s Birthday______________________________________________
Wedding Anniversary___________________________________________________
How did you find out about us?___________________________________________
What is it you most hope to gain from our club? Please mail to:
______________________________________
______________________________________
Debbie
Hefner
______________________________________
5424 Dusty
Rd.
______________________________________
______________________________________ 828-256-5991
______________________________________ dlcph@yahoo.com
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