Membership Form

Name __________________________________________________ Chapter # _____________

Current and/or former occupation __________________________________________________

I heard about Mothers & More from ________________________________________________

_____Please tell me about how to start a chapter in my area

Membership fees (in U.S. funds)

_____ One–year membership (United States) $45
_____ One–year membership (International) $55
_____ Here’s my tax–deductible donation of $__________
            to help with support and advocacy work.
_____ Send a gift membership (additional $45 or $55 enclosed)
           to the person named below:
           Recipient’s name _____________________________________

           Address ____________________________________________

           City/State/Zip ________________________________________

Method of payment