Mariposas On The Move Member Sign Up

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Name/Nombre
First Name/Primer Nombre
Last Name/Apellido
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E-mail/Correo Electronico
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Phone Number/Numero de Telefono
Area Code
Phone Number
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Address/Direccion
Street Address/Direccion de Domicilio
Street Address Line 2
City/ciudad
State/Estado
Zip code/Codigo Postal
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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T-Shirt Size/Talla de Camiseta:
S
M
L
XL
XXL
Other
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Favorite Color/Color Favorito :
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Favorite snacks/candy: Bocadillos/ Dulces Favoritos:
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What part of motherhood are you in? (e.g., expecting, new mom, experienced mom, etc.) ------¿En qué etapa de la maternidad te encuentras? (por ejemplo, ¿estás embarazada, eres madre primeriza, eres madre experimentada, etc.)?
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What made you reach out to Mariposas on the Move? Que te hizo contactar a Mariposas en Movimiento?
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How would you like to be involved in the Mariposas on the Move community (e.g., attending events, volunteering, mentoring)? ¿Cómo le gustaría participar en la comunidad de Mariposas en Movimiento (por ejemplo, asistiendo a eventos, haciendo voluntariado, asesorando)?
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Would you be interested in joining a support group or workshop? ¿Estaría interesada en unirse a un grupo de apoyo o taller?
Yes/SI
No
Maybe-Would like more information
Talvez-Me gustaria mas informacion
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Would you like to share your motherhood journey on Mariposas Monthly Podcast? ¿Te gustaría compartir tu experiencia como madre en el podcast mensual de Mariposas?
Yes/Si
No
Maybe-Would like more information
Talvez-Me gustaria mas informacion
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What challenges are you currently facing in your motherhood journey? P there specific resources or support you’re looking for at this time? ¿A qué desafíos te enfrentas actualmente en tu camino como madre?¿Estás buscando recursos o apoyo específicos en este momento?
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How do you prefer to be contacted? ¿Cómo prefieres que nos comuniquemos contigo?
Text/Texto
Email/Correo Electronico
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SignatureEnglish: By signing below, I consent to participate in the programs offered by Mariposas on the Move and give permission for the organization to use the information provided to better assist in offering support and services. I understand that all personal information will be kept confidential and will only be used for the purposes of this program. Español: Al firmar a continuación, doy mi consentimiento para participar en los programas que ofrece Mariposas on the Move y autorizo a la organización a utilizar la información proporcionada para brindar un mejor apoyo y servicios. Entiendo que toda mi información personal se mantendrá confidencial y se utilizará únicamente para los fines de este programa.
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I give my consent to Mariposas on the Move to take and use photographs and/or videos of me and my child(ren) during events and activities hosted by the organization. I understand that these images may be used in promotional materials, social media, website content, and other media platforms to support the mission and outreach efforts of Mariposas on the Move.-----------------------------------Doy mi consentimiento a Mariposas on the Movepara tomar y usar fotografías y/o videos de mí y de mi(s) hijo(s) durante eventos y actividades organizados por la organización. Entiendo que estas imágenes pueden ser utilizadas en materiales promocionales, redes sociales, contenido del sitio web y otras plataformas de medios para apoyar la misión y los esfuerzos de alcance de Mariposas on the Move.
YESNO
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I acknowledge and confirm my response to the photo release, indicating my consent (Yes) or non-consent (No) as specified above.----Reconozco y confirmo mi respuesta a la autorización de uso de fotografías, indicando mi consentimiento (Sí) o mi no consentimiento (No) arriba.
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