New Customer Registration Form

Name

First NameLast Name

E-mail*

Birthday (Mom)

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Please list your child(rens) name(s), age(s), birthdate(s):

What aspect/s of the MOMS Club are you most interested in?

What are your interests and hobbies?

How did you hear about the MOMS Club of Bend?

Does your child have any allergies, if so, please list:

Social Media Photo Consent

I give my permission to the MOMS Club of Bend to use photos of me or my child/ren on the MOMS Club website and public facing social media sites (e.g. Facebook, Instagram).I DO NOT give my permission to the MOMS Club of Bend to use photos of me or my child/ren on the MOMS Club website and public facing social media sites (e.g. Facebook, Instagram).

My Products

USDDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

WAIVER OF LIABILITY

I understand that the MOMS Club requires me to be responsible for the safety and conduct of myself, my family members, and my guests, while participating in all MOMS Club activities. I also understand that the MOMS Club requires all other members to be similarly responsible for themselves, their families and their guests. I therefore make the following agreements: I release the MOMS Club from any obligations or duty of care owed to me or to any individuals for whom I am responsible. I waive any and all liabilities or claims I may have or individuals for whom I am responsible may have, against MOMS Club for personal injuries or property damages arising out of our participation in MOMS Club functions or activities connected to the MOMS Club, including liability for the negligence of the MOMS Club, its Board Members, Coordinators, Sponsors, Representatives or Members. I agree to indemnify the MOMS Club for any and all liabilities and claims arising from my own conduct or negligence, or the conduct and negligence of individuals for whom I am responsible. I accept that my participation in any MOMS Club functions will be voluntary and I assume all risks related to my participation and activities connected with the MOMS Club, and all such risks to individuals for whom I am responsible.
NO WARRANTIES I acknowledge that the MOMS Club makes no warranties regarding insurance coverage for any member, participant, host, sponsor, or facility connected with the MOMS Club activities and functions.
TERM I agree that this release shall be effective as long as I participate in activities connected to the MOMS Club, regardless of membership.

Signature

Mom's Club Registration Form