INFORMATION ABOUT YOU:

Membership Status (please check one):

New Member Renewal

First Name:
Last Name:

Birthdate: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 other

Mailing Address:

City: State Zip:

Tel: Email:

Your Occupation:

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INFORMATION ABOUT YOUR SPOUSE/PARTNER:

First Name:
Last Name:

Spouse's/Partner's Birthdate: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 other

Spouse's/Partner's Occupation:

Anniversary Date (if applicable): Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 other

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ARE YOU PREGNANT?:

Are you pregnant? Choose... No (skip to next section) Yes w/Twins Yes w/Triplets Yes w/Higher Order Multiples

What is your due date?

I / We are having: Choose... Identical Fraternal We don't know yet

Do you know the gender? Choose... Boys Girls Boy/Girl

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INFORMATION ABOUT YOUR CHILDREN:

I / We have: Choose... Twins Triplets Higher Order Multiples

Multiples Gender? Choose... Boys Girls Boy/Girl Multiple Type: Choose... Identical Fraternal Unknown

Please list all your children including multiples and other siblings:

Name: Gender :Boy Girl
Birthdate

Name: Gender :Boy Girl
Birthdate

Name: Gender :Boy Girl
Birthdate

Name: Gender :Boy Girl
Birthdate

Name: Gender :Boy Girl
Birthdate

Name: Gender :Boy Girl
Birthdate

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OTHER HELPFUL INFORMATION ABOUT YOU:

In an effort to reach other parents of multiples, it would be helpful to know how you heard about TPOM? Please Select One Friend Through another member Through my OB Through my hospital Puget Sound Parent Magazine NW Baby Magazine Other Publication Online via Google Online via Yahoo Through NOMOTC Other Online Other

Is there a service that you or your spouse/partner could provide to the group (ie: Mary Kay, Financial Consultant, Scrapbooking etc.?) If yes, please indicate in the box below:

Do you have a special talent, ability or skill that could benefit the group? If yes, please indicate in the box below:

In an effort to save on costs, we like to communicate with our members as much as possible online through our member-only community and via email. Please indicate by checking the box below if we may contact you via email.

Yes! I'd like to help save operating costs and can receive communication from TPOM via email.