New Chapter Registration Form Print this form, sign it and mail it to the address below. Be sure to include a check for $30 for your chapter's first registration fee. (For International founders, outside the US, please make check payable in "US Funds.") As your chapter gets going, you will be paid back from its treasury. We will send you your MOMS Club membership pin, your chapter's manual and start-up materials when your new chapter has been approved by our Regional Coordinator for your area. Name:___________________________________________________________________ Address:_________________________________________________________________ City/State/Zip: ___________________________________________________________ Telephone: (_____)__________________ E-mail: ____________________________ Usually one mother starts a chapter, but if anyone is helping you, please include their names and addresses on a separate sheet of paper. The International MOMS Club will designate a geographic territory for your group based on the demographics of your area, but if you have a preference, please note it here: ________________________________________________________________________ I, the undersigned at-home mother, wish to start a local MOMS Club for the at-home mothers in my community. This MOMS Club shall be operated in a nonprofit manner and shall not be used for business, political or religious purposes. I want this chapter to be included under the International MOMS Club's nonprofit status. Enclosed is a check for $30 for this group's first annual registration fee. ______________________________________________________________________ Founding At-Home Mother                                          Date (Allow 6-8 weeks for delivery. $30 registration fee not refundable by the International MOMS Club due to the cost and high quality of materials sent to new group Founders. All Founders are to be reimbursed by the chapters they start.) Send to:    New Groups International MOMS ClubSM 1464 Madera Rd. #N 191 Simi Valley, CA 93065