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Online Membership Form

Please make sure payment is made after completing the form.

*If you need to type in dates use this dd-mm-yyyy format

Date*:

Please complete the form for new membership applications only. Please see Membership Renewal form for renewals

Parent 1 Full Name (required):

Parent 1 Occupation:

Parent 2 Full Name:

Parent 2 Occupation:

Address (required):

Phone (required):

Mobile:

Your Email (required):

Parent 2 Email:

DETAILS OF MULTIPLES
Due Date*: Or Actual Birth Date*: (If Already Born)

WHAT COMBINATION OF MULTIPLES DO YOU HAVE?
 Twins (Identical) Twins (Fraternal) Triplets (All Identical) Triplets (All Fraternal) Triplets (2 Identical + 1 Fraternal)

Quads (Please describe combination):

Other (Please describe combination):

MULTIPLES FULL NAME

1: Full Name: Gender: Weight (in Kg): Gestation (in weeks):

2: Full Name: Gender: Weight (in Kg): Gestation (in weeks):

3: Full Name: Gender: Weight (in Kg): Gestation (in weeks):

4: Full Name: Gender: Weight (in Kg): Gestation (in weeks):

DETAILS OF OTHER CHILDREN (If Applicable)

1: Child's Full Name: Gender: Date Of Birth*:

2: Child's Full Name: Gender: Date Of Birth*:

3: Child's Full Name: Gender: Date Of Birth*:

4: Child's Full Name: Gender: Date Of Birth*:

5: Child's Full Name: Gender: Date Of Birth*:

6: Child's Full Name: Gender: Date Of Birth*:

How would you like to receive your monthly Multiplicity (CDMBA newsletter)?  Email Australia Post

YOUR PERMISSIONS

Do you give permission for Casey & District MBA Inc to print your family’s given names (this includes welcome, birth notices, birthdays, articles etc) in:

The club newsletter  Yes No

The club website  Yes No

Do you give permission for Casey & District MBA Inc to use photos of your children/family in:

The club newsletter  Yes No

The club website  Yes No

Do you give permission for Casey & District MBA Inc to use photos of your children/family on our Facebook site, other Social Media, or for Publicity opportunities?
 Yes No

If you are a parent of a child/children with a disability, please give brief details:

Do you speak another language/s at home? If so, please list:

How did you find out about us? AMBA Club finder CDMBA Website Word of mouth Internet search White pages Other 

Any other comments?

Please make payment following submission of this form via money order made out to:
Casey & District Multiple Birth Association Inc.
PO Box 37, Hampton Park, VIC, 3976

OR

Direct Deposit
Bank: Westpac, Account name: CDMBA Membership, BSB: 033341, Account No: 677782

Joining Fee:
$40 Per Year (year commences on 1st April)

$60 Per 18 months (from 1st October)

2 Year Membership $70 Discounted rate

I would like to make a donation to Casey & District Multiple Birth Association Inc.

to the amount of $.Please add this amount to your membership fee.

Donations of $2.00 or more are tax deductible.

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