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Membership Application

Note: You must be a parent/guardian of multiples (twins, triplets, etc.) in order to join POMBA.

POMBA Membership Fees are as follows:

Family Membership: $30.00 per year, renewable on July 1
Membership is prorated to $15 if you join between January 1st and June 30th
Single Parent Membership: $25.00
Out of Town Membership (more than 100 km from HRM): $25.00
Alumni Membership (Multiples over 12): $15.00

Please fill out the form below.

Your Name and Contact Information
Your First Name:
Your Last Name:
Spouse / Partner's Name (Optional):
Address:
Address 2 (Optional):
City:
Province:
Postal Code:
Phone:
Fax (Optional):
E-mail Address (Optional):
Alternate E-mail Address (Optional):
Online Profile Information
Would you like to have access to the POMBA Members only area of the POMBA Website?	Yes No
Username:
Password:
Confirm Password:
Information About Your Multiples
Due Date (if expecting):
Type of Multiple:	Twins Triplets More
1. Child's Name:
1. Child's Birthdate:	Month: Day: Year:
2. Child's Name:
2. Child's Birthdate:	Month: Day: Year:
3. Child's Name:
3. Child's Birthdate:	Month: Day: Year:
4. Child's Name:
4. Child's Birthdate:	Month: Day: Year:
Information About Your Other Children
1. Child's Name:
1. Child's Birthdate:	Month: Day: Year:
2. Child's Name:
2. Child's Birthdate:	Month: Day: Year:
3. Child's Name:
3. Child's Birthdate:	Month: Day: Year:
Other Information
Include your name and phone number on our membership list (member use only)? Yes No
Are you interested in volunteering some time to POMBA? Do you have any special skills or resources that we can call on? Please let us know!

Are there any specific POMBA programs or activities you would like more information on?

Payment Information
Choose Membership Type:	Membership Dues are Pro-Rated to $15 for registrations between Jan 1 and Jun 31 Family Membership: $15.00 for current year, renewable on July 1 at $30.00 Single Parent Membership: $15.00 for current year, renewable on July 1 at $25.00 Out of Town Membership (>100 km from HRM): $15.00 for current year, renewable on July 1 at $25.00 Alumni Membership (Multiples over 12): $15.00
Please choose your preferred payment method:	Mail in Personal Check or Money Order Pay with Credit Card (via PayPal) NOTE: Credit Card Fees are added to the membership fees (ie. $30 membership is charged as $31.42)
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