Membership Demographic Survey

The purpose of this survey is to compile a complete and accurate membership database for the Texas Mothers of Multiples. This will allow for better dissemination of information as well as allowing the group to offer more to its members based on their needs.

Please provide the following information

* First Name :

* Last Name :

Address 1 :

Address 2 :

City :

State :

Zip :

Phone :

Email Address :

* Please provide the name of the local club you belong to (no acronyms):

I have:

My Multiples are the following sexes (g=girl, b=boy, o=other):

Are you a single parent?

Yes

No

Prefer Not to Answer

Are you the parent of a special needs child?

Yes

No

Prefer Not to Answer

I am currently serving on the following TMOM Committees(Select all that apply):

I am currently serving on my Local Board in the following position (Select all that apply):