Twins Plus Association of Brampton
Member Registration Form 2012
218
Ecclestone Drive, Brampton, ON L6X 3P9
brampton@multiplebirthscanada.org
Name: ______________________________________ Membership #:
_____________________
Spouse: _____________________________________ E-mail:
____________________________
Address: ___________________________________________________________________________
City: _____________________________ Postal
Code: ________________________
Home Phone: ______________________ Alternate
Phone: _____________________
Expecting OR Have Twins Triplets Quads
Due Date: ______________
Children’s First and Last Names M/F Date of Birth
___________________________________ _____ ______________________________
___________________________________ _____ ______________________________
___________________________________ _____ ______________________________
___________________________________ _____ ______________________________
___________________________________ _____ ______________________________
Would you like to join any of these MBC
support chapters?
High Order Multiples
_____ Father _____ Lone Parent _____ Breastfeeding _____
Special Needs _____ Loss _____ Francophone _____ Adult Multiples _____
Please specify if
you would like support in any other area?
_____________________________________
How did you hear about our TPAB? ______________________________________________________
Please read the following statement and
initial below to agree or disagree:
I authorize
publication of any photos that are taken of my children at Twins Plus
Association of Brampton (TPAB) events in TPAB or Multiple Births Canada
publications or on the websites or Facebook pages of these two organizations
only. This does not imply authorization
to publish my children’s’ photographs in any newspaper or other media
outlet.
I agree_____________ I
disagree___________________
Annual
Membership Fee: $30.00 (Includes membership to TPAB and Multiple Births Canada)
*By becoming a
member of the TPAB and paying the membership fee, I agree to have my name,
address, phone number and email address published on the TPAB membership list
for distribution ONLY to the Executive Team Members of TPAB and MBC when
necessary and in accordance with the Personal Information Protection and
Electronic Documents Act. TPAB promises
to never share your information with any other members and with any outside
parties.
Please indicate if you would you be interested
in volunteering? Yes _____ No _____
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