Online Membership Form

To our new members, we are so excited that you have decided to join the East County Mothers’ Club. And to those of you renewing we are very happy that you’ve decided to stay with us. The East County Mothers’ Club has so many wonderful programs and events to offer you and your families and we think you’ll have a wonderful time.

Please fill out the online form below. After completing this form, you will have the opportunity to pay securely on-line via PayPal.

You can also email us at membership@eastcountymothersclub.org or call 925-473-2783 to have a form sent to you.

Once you have paid dues and become a member (you will receive an email within a week), you may start participating in all areas of the club. We use the information on the form below to provide a broad range of services available to you. Some of this information will be included in the ECMC roster that is published and distributed to our membership so that we can stay in touch with each other. No membership information is shared with any outside organization or with any of our advertisers.

Member Info
First Name	*		* required fields
Last Name	*
Address	*
City	*
State	*
Zip	*	(5 or 9 digits)
Home phone	*	(include area code)
Email Address	*
Re-enter Email Address	*
Birthday		/ (mm/dd)

Partner Info

Partner's First Name

Partner's Last Name

Children
(If pregnant, write "Expecting" and due date)
Children's Names	Gender	Dates of Birth
(First and Middle) (Last)		(or Due Date) (mm/dd/yyyy)

		/ /
		/ /
		/ /
		/ /
		/ /


By submitting this form, I acknowledge that I have read, understand and will adhere to the East County Mothers’ Club By-laws and therefore will be responsible for the safety and behavior of my family and guests at all club functions.
Please review your information for accuracy before submitting. Once you click submit your information is sent.

If you encounter any difficulties with the online registration process, please contact membership@eastcountymothersclub.org or call 925-473-2783. East County Mothers’ Club P.O. Box 4687 Antioch, CA 94531

Other Info
Occupational situation
		Stay at home mom		Part-time outside the home
		Full-time outside the home		Work from home
Privacy Notice
Some of this information will be made available to other members in our Club roster. If you have any information which you would not like shared, please let us know here.
		You can share some of my information, but NOT the following:
		Email Address Phone

		Photo Release
		By checking this box I give the East County Mothers’ Club permission to publish in print, electronic or video format, the uses of which may include but are not limited to videotapes, photographs, displays, brochures, Web sites, multi-media programs, or any other type of promotional medium, the likeness or image of my child and/or myself and family. I release all claims against ECMC with respect to copyright ownership and publication including any claim for compensation related to use of the materials.
Tell Us What You Think
The ECMC is run completely by volunteers. All members are required to volunteer a minimum of 2 hours to the club during the year. If you are unable to volunteer this year, please select to pay the full dues ($50) as your payment option below. In which activities would you like to participate to fulfill your requirement?
	Cooking In-A-Pinch Meals		Social Events		Community Outreach
	I would like to cook IAP Meals		Fall Social - Halloween Party (Oct.)		Organizing the Annual Preschool Fair
			Winter Social (Jan.)		Preparing Mother’s Day Bags for shelter
			Spring Social - Easter Egg Hunt (April)		Independence Day Parade
			Summer Social (July or Aug.)		Assisting in a "drive" (i.e. coats, school, toys)
			Meet and Greets		Trick-or Treating Event
	Fundraising		Membership Drive
	Holiday Gift Wrapping		Help Recruit New Members All Year		Sub-Clubs (check all that are of interest)
	Garage Sale		Help recruit new members at the beginning of the new year (August and September)		Mommies Making Memories - Scrapbook/Photography Club
	Pizza Night				Book Club
	Creating New Fundraisers				Mom's Night Out - "It's a Lifesaver"
					Grape Expectations - Wine Club Striders - Walking Club Healthy Hotties - healthy living Reel Women's Movie Club Bunco Toy Lending Library

What do you hope to get out of the club in the upcoming year? (Select only the relevant answers. Please rank your choices, 1=MOST important, 3=LEAST important.)
	Rank			Rank
	1	2	3	1	2	3
	Play dates for my children			Weekend activities
	Meet families in the community			Enjoy the newsletter
	Outings for children			Social activities for families
	Community service opportunities			Access to parenting resources, i.e. finding a babysitter, doctor, etc.
	Social activities for moms
	Advice from other moms
	Meet other working moms
	Other (please specify)

Where did you hear about us?
Online Other Media Friend Other
New Member Biography (Optional)
Where were you educated and what level of education (including degree and major, if any) did you receive?
Where have you lived since your education and prior to moving here?
How long have you lived in the area?
What does your partner do?
What is your current job (in addition to being a mom), if any?
If not employed now, what was your previous job?
What are your hobbies?
Payment Options
Will you be paying by mail or online through Paypal with a credit card (or an existing Paypal account)?
	Send Check by Mail (please print form and mail with check) Pay Online through Paypal (use submit button below)

	$35 (Discounted dues with online monthly newsletter.) $50 (Full dues including hard copy of newsletter mailed to your home.) $50 (I do not wish to volunteer this year. Full dues with online monthly newsletter.) $50 (I do not wish to volunteer this year. Full dues including hard copy of newsletter mailed to your home.)