COREN MOMS CLUB UGANDA

        MEMBERSHIP APPLICATION FORM

NB. Please scan your signature or thumb print and paste it on this form

 Name:……………………………………………………………………………………………………………….

Address:……………………………………………………………………………………………………………..

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City:……………………………………………………………………str………………………………………….

Country……………………………………………………………………………Zip……………………………..

Mail…………………………………………………….............................................................................................

Tel…………………………………………………………………………………………………………………..

What type of mom are you?

Iam…………………………………………………………………………………………………………………

What type of activity can you do ?

……………………………………………………………………………………………………………………..

Will you be available for conferences, workshops if need be?

Please tick.      Ye s      ………….         No…………………….

If No please give reasons.

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Signature…………………………………………………….Date…………………………………………………