Southold Mothers' Club - Southold New York

Please print this page, then fill out the form and send this completed application along with the subscription fee of $25.00 to the address at the bottom.

Southold Mothers' Club Membership Application

Name:

Please list your interests & hobbies:

Address:

Address 2:

Phone:

Your Birthday:

Your Spouse's Name:

Childrens' Names and Birthdates:
1. _____________________________________
2. _____________________________________
3. _____________________________________
4. _____________________________________
5. _____________________________________

E-mail address:

Emergency Contact:

This information is used to announce birthdays in our newsletter and to set up playgroups. We do not give any information about you or your children to any other organization or company.

Please print this page, then fill out the form and send this completed application along with the subscription fee of $25.00 to:

The Southold Mothers' Club
PO Box 1133
Cutchogue, NY 11935
Attn: Treasurer