ࡱ> $'!"#M Nbjbj== pWW7 l4$$$h$&\~xt'7777<?Avzwwwwww$y |3w]B;0<]B]B3wH778xHHH]B77vH]BvH:HKNRkn7' Ex $ClnNx0~xl|H|nHMembership Form PLEASE COMPLETE USING MS WORD OR PRINT CLEARLY Newsletter: Are you willing to receive the monthly newsletter via the Website instead of a paper copy?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If yes, please provide e-mail address to receive notifications:  FORMTEXT       Personal InformationName FORMTEXT      Birth Date: FORMTEXT      / FORMTEXT       (Month/Day format)Spouse s Name FORMTEXT      Birth Date: FORMTEXT      / FORMTEXT       Anniversary FORMTEXT      / FORMTEXT      Address FORMTEXT      E-mail Address: FORMTEXT      City, State Zip FORMTEXT      Home Phone: FORMTEXT      Do you work outside the Home? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, work phone: FORMTEXT      Do you work FROM home? FORMCHECKBOX  Yes  FORMCHECKBOX  NoOccupation: FORMTEXT      Occupation before children FORMTEXT      Spouses Occupation FORMTEXT      How did you hear about CAMOM?  FORMTEXT      Children s Information (Types: Identical, Fraternal, Not sure, Singleton) NameBirthdateGenderMultipleTypeNotes FORMTEXT       FORMTEXT      / FORMTEXT      / FORMTEXT      M FY NI F N S FORMTEXT       FORMTEXT      / FORMTEXT      / FORMTEXT      M FY NI F N S FORMTEXT       FORMTEXT      / FORMTEXT      / FORMTEXT      M FY NI F N S FORMTEXT       FORMTEXT      / FORMTEXT      / FORMTEXT      M FY NI F N S FORMTEXT       FORMTEXT      / FORMTEXT      / FORMTEXT      M FY NI F N S FORMTEXT       FORMTEXT      / FORMTEXT      / FORMTEXT      M FY NI F N S FORMTEXT       FORMTEXT      / FORMTEXT      / FORMTEXT      M FY NI F N S Are you currently expecting? How many?  FORMTEXT       Sex(s) (if known):  FORMTEXT       Due Date:  FORMTEXT        CAMOM s membership year begins in August. New members may join at anytime throughout the year, however dues are not prorated. Renewing Members Dues are $25 a year and include membership to the Palmetto State Parents of Multiples (PSPM) and the National Organization of Mothers of Twins Club (NOMOTC)  Please make check payable to CAMOM. Bring your check and form (if completed on paper) to the meeting or mail to: CAMOM P.O. Box 60297 North Charleston, SC 29419  HYPERLINK "mailto:camomclub@aol.com" camomclub@aol.com Visit our CAMOM website:  HYPERLINK "http://www.camom.org" www.camom.org Getting to Know You Information provided here is a fun get-to-know-you sheet. Information may be used in the newsletter or on the website. Name FORMTEXT       Hometown  FORMTEXT       College  FORMTEXT       Special Interests  FORMTEXT       How I spent my time before becoming a Mom:  FORMTEXT       How my husband & I met:  FORMTEXT       Something I am looking forward to:  FORMTEXT       What I learned upon becoming a Mother of Multiples:  FORMTEXT       How would you spend an entire day to yourself?  FORMTEXT       Our reactions when we found out we were having multiples:  FORMTEXT       How have I become like my Mother:  FORMTEXT       A little known fact about myself:  FORMTEXT       Best advise you were given:  FORMTEXT       The nicest thing someone has said to me regarding my multiples:  FORMTEXT       My favorite twin/triplet or more story:  FORMTEXT       Reason for joining CAMOM:  FORMTEXT       Member Information & Support For information and support purposes, please provide information regarding your pregnancy and your children. Please note, your privacy is important to us. Information collected here is for CAMOM use in determining demographics, interests, and providing support to members. Information is used exclusively for CAMOM, and will not be sold or shared outside of the Mothers of Multiples. For member support purposes, Are you willing to talk with other members about these conditions? If yes, please check the second box (in addition to the first) for each condition. Your name:  FORMTEXT       SAMPLE: Check here if have  FORMCHECKBOX  Condition  FORMCHECKBOX  check here if willing to talk with other members about your experiences Children FORMCHECKBOX  Asthma  FORMCHECKBOX  FORMCHECKBOX  Heart Murmur PDA  FORMCHECKBOX  FORMCHECKBOX  Perinatal / Infant Loss  FORMCHECKBOX Please List Other Conditions: FORMCHECKBOX  Blindness  FORMCHECKBOX  FORMCHECKBOX  Heart Murmur VSD  FORMCHECKBOX  FORMCHECKBOX  Reflux  FORMCHECKBOX  FORMCHECKBOX  Cerebral Palsy  FORMCHECKBOX  FORMCHECKBOX  Home monitors  FORMCHECKBOX  FORMCHECKBOX  Speech  FORMCHECKBOX  FORMCHECKBOX  Closure of VSD  FORMCHECKBOX  FORMCHECKBOX  Hypospaidias  FORMCHECKBOX  FORMCHECKBOX  Tonsillectomy  FORMCHECKBOX  FORMCHECKBOX  Cranial Asymmetry  FORMCHECKBOX  FORMCHECKBOX  Jaundice  FORMCHECKBOX  FORMCHECKBOX  Torticollis  FORMCHECKBOX  FORMCHECKBOX  Downs Syndrome  FORMCHECKBOX  FORMCHECKBOX  Jaundice home treatment  FORMCHECKBOX  FORMCHECKBOX  Tubes in Ears  FORMCHECKBOX  FORMCHECKBOX  Feeding Problems  FORMCHECKBOX  FORMCHECKBOX  Lazy Eye  FORMCHECKBOX  FORMCHECKBOX  Vascular Ring  FORMCHECKBOX  FORMCHECKBOX  Feeding Tubes  FORMCHECKBOX  FORMCHECKBOX  Low Glucose Levels  FORMCHECKBOX  FORMCHECKBOX  Visual Impairment  FORMCHECKBOX  FORMCHECKBOX  Food Allergies  FORMCHECKBOX  FORMCHECKBOX  Nystagmus  FORMCHECKBOX  FORMCHECKBOX  Other  FORMCHECKBOX Pregnancy-Related FORMCHECKBOX  Anemia  FORMCHECKBOX  FORMCHECKBOX  Post Partum Depression  FORMCHECKBOX Please List Other Conditions: FORMCHECKBOX  Bedrest  FORMCHECKBOX  FORMCHECKBOX  Pre-Eclamsia  FORMCHECKBOX  How long?  FORMTEXT       FORMCHECKBOX  Premature Birth  FORMCHECKBOX  # of wks  FORMTEXT      If not premature, # Weeks at delivery:  FORMTEXT       FORMCHECKBOX  Chlomid  FORMCHECKBOX  FORMCHECKBOX  Pre-Term Labor  FORMCHECKBOX  # of wks  FORMTEXT       FORMCHECKBOX  Gestational Diabetes  FORMCHECKBOX  FORMCHECKBOX  Reflux  FORMCHECKBOX  FORMCHECKBOX  IUI  FORMCHECKBOX  FORMCHECKBOX  Terbutaline  FORMCHECKBOX  FORMCHECKBOX  IVF  FORMCHECKBOX  FORMCHECKBOX  Twin-to-Twin Transfusion  FORMCHECKBOX  FORMCHECKBOX  Ovarian Thrombosis  FORMCHECKBOX  FORMCHECKBOX  Vanishing Twin Syndrome  FORMCHECKBOX  FORMCHECKBOX  Polycystic Ovaries  FORMCHECKBOX  FORMCHECKBOX  Other  FORMCHECKBOX  Other Support / Discussion Topics you have experience with (and would be willing to be an expert for: FORMCHECKBOX  Breast Feeding  FORMCHECKBOX  FORMCHECKBOX  Home Schooling  FORMCHECKBOX  FORMCHECKBOX  Potty Training  FORMCHECKBOX  FORMCHECKBOX  Traveling with Kids  FORMCHECKBOX  FORMCHECKBOX  Breast Pumping  FORMCHECKBOX  FORMCHECKBOX  Infertility Issues  FORMCHECKBOX  FORMCHECKBOX  Safety Devices  FORMCHECKBOX  FORMCHECKBOX  Triplet Mom  FORMCHECKBOX  FORMCHECKBOX  Camping with  FORMCHECKBOX  FORMCHECKBOX  Kids close in Age  FORMCHECKBOX  FORMCHECKBOX  Single Parent  FORMCHECKBOX  FORMCHECKBOX  Working-from-Home  FORMCHECKBOX  FORMCHECKBOX  Cloth Diapers  FORMCHECKBOX  FORMCHECKBOX  Large Family  FORMCHECKBOX  FORMCHECKBOX  Stay-at-Home Dad  FORMCHECKBOX  FORMCHECKBOX  Working-outside-home  FORMCHECKBOX  FORMCHECKBOX  Divorce Recovery  FORMCHECKBOX  FORMCHECKBOX  Moving with Kids  FORMCHECKBOX  FORMCHECKBOX  Stay-at-Home Mom  FORMCHECKBOX  FORMCHECKBOX  Other  FORMCHECKBOX  (list other topics on reverse) Additional Notes or comments:  FORMTEXT       Member Interest & Participation Form CAMOM is whatever we, the members, make it. Do you want a club rich in educational opportunities? Do you want a club with lots of social activities for moms and children? Would you prefer more adult activities Moms nights out, or with spouses? Would you like a club with a strong state and local presence? Would you like a club that reaches out into the community and helps moms, children, and families? Please take a few minutes to answer the questions below to help give our club direction in the way that it will best benefit you! Your name:  FORMTEXT       What CAMOM opportunities are Important to YOU?  FORMCHECKBOX  Board Meeings (Sunday following 2nd Tuesday)  FORMCHECKBOX  Borrow books from club library  FORMCHECKBOX  Breakfast with the Girls (weekday mornings, no kids)  FORMCHECKBOX  Education and support on parenting  FORMCHECKBOX  Education and support on pregnancy  FORMCHECKBOX  Family Activities (Saturdays)  FORMCHECKBOX  Family Activities (Weeknights)  FORMCHECKBOX  Meetings (2nd Tuesday, 7 p.m.)  FORMCHECKBOX  Moms Night Out (movies and/or dinner w/ no kids)  FORMCHECKBOX  Mom-to-mom contact  FORMCHECKBOX  New & Expectant Mom discussion groups (7 p.m.)  FORMCHECKBOX  New & Expectant Mom discussion group (11 a.m. bring babies)  FORMCHECKBOX  Parent Socials (no kids)  FORMCHECKBOX  Playgroups in the Afternoon (M-F)  FORMCHECKBOX  Playgroups in the Morning (M-F)  FORMCHECKBOX  Playgroups on Saturday Afternoon  FORMCHECKBOX  Playgroups on Saturday Morning  FORMCHECKBOX  Read club newsletter  FORMCHECKBOX  Selling at Clothing & Equipment Sale  FORMCHECKBOX  Shopping at Clothing & Equipment Sale  FORMCHECKBOX  State Convention  FORMCHECKBOX  Support from other Moms What are you Willing to Give? Note, this is NOT about money. It is about ideas, talents and a little bit of time! Are you willing to pass out flyers promoting our Sale at your church, daycare, workplace, etc?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Would you like to help PLAN our State Convention? We are hosting Down by the Shore in 2004.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Would you like to ATTEND our State Convention?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you have any ideas for Educational Programs for meetings? (parenting or family or womens issues)  FORMCHECKBOX  Yes  FORMCHECKBOX  No For moms-to-be? (list on back of form)  FORMCHECKBOX  Yes  FORMCHECKBOX  No For other moms or families in Charleston? (list on back of form)  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to provide copies of pictures you take at club activities to the club?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you like to scrapbook?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to contribute articles, funnies, and other info to the club newsletter?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to plan ONE club social function?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to plan ONE Moms Nights Out?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to coordinate playgroups and prepare the monthly calendar for the newsletter?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to hostess a playgroup at your house?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to be a contact-hostess for a playgroup at a park, restaurant or mall?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to serve as club librarian, making books available to members?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to write a book review on a book in our library for the newsletter?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to call a prospective member to say hello and welcome?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to make 3 reminder phone calls before club events?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you interested in serving as contact person for information concerning the National Organization and keeping the club informed of national information, research, surveys, etc.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you interested in CAMOM community service: Donating baby & childrens items to childrens charities  FORMCHECKBOX  Yes  FORMCHECKBOX  No Volunteering for childrens charities  FORMCHECKBOX  Yes  FORMCHECKBOX  No Visiting Nursing homes  FORMCHECKBOX  Yes  FORMCHECKBOX  No Making items for Newborns in Need  FORMCHECKBOX  Yes  FORMCHECKBOX  No Volunteering time for womens charities  FORMCHECKBOX  Yes  FORMCHECKBOX  No Volunteering at soup kitchen  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to post 5 flyers in public places mommies frequent?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to provide club info to your pediatrician, OB/GYN, and pediatric dentists offices?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to coordinate the above activities, and provide news releases and public service announcements to the media as needed to promote the club and its activities?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to call and offer support to moms on bed-rest or hospitalization?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to call a new mom once a week for 6 weeks after her delivery & offer support?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you willing to provide a meal to a mom and family (in your area) after delivery of their multiples?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you have an opinion on how CAMOM should spend its budget?  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