Kona Moms 2014-2015 Registration Form Name: ____________________________________________________________________________ Mailing Address: _____________________________________________________________________ Phone: _____________________________E-Mail: __________________________________________ Emergency Contact Name: _______________________________ Phone: _________________________ Birth Date (Month/Day): _____________Occupation if currently working: __________________________ Currently Pregnant? YES / NO If yes, when is your due date? _________________________________ Any dietary restrictions? (ex: vegan, dairy-free, nut allergy, etc.) ___________________________________ Can we include your name, your children’s names and your e-mail address in our directory? YES / NO We take photos at our events. Can we use photos of you or your children to promote Kona Moms? YES / NO Significant Other’s Name: ___________________________________________________________ Child #1 Name _______________________________________DOB (M/D/Y) ________________ Child #2 Name _______________________________________DOB (M/D/Y) ________________ Child #3 Name _______________________________________DOB (M/D/Y) ________________ Child #4 Name _______________________________________DOB (M/D/Y) ________________ Are you interested in joining a babysitting co-op with other moms in the group? YES / NO We will have “mentor moms” and community experts at every meeting teaching us about all sorts of topics relevant to moms. If you have any special skill, occupation, talent, inspirational story, or volunteer work that you are willing to share with the other moms during a meeting, please list it below (ex: yoga instructor, banker, recycler, chef, doctor, gardener, human resources, world traveler, educator, tie-dyer, scrap booker, realtor, etc.)

We believe participation enhances your experience in Kona Moms. Please check any committees you would like to help with:  Halloween Party (October)  Holiday Party (December)  Family Fun Day (February)  Easter Egg Hunt (March)  Community Service (Ongoing)  Children’s Activity Board (Ongoing)  Community Service (Ongoing)  Babysitting Co-op (Ongoing) Do you have any special event or activity suggestions? Any topics you would like to see discussed? (ex: volunteer work, ladies night, scrapbooking party, bowling, money saving tips, bunko, resume writing, etc. )

We want moms to have special “mommy time” together so we will have day care available for all meetings. If your child is under 18 months, this is optional. If your child(ren) will be attending meetings, please list the name(s) of your child(ren) you will be enrolling in day care and any special health needs like allergies, medications, etc. (Note: If bringing children over 18 months old, they must be enrolled in the day care program):

Dues without daycare: $65 Dues with 1 child in daycare: $95 Dues with 2 or more children in daycare: $115 Please make checks payable to Kona Moms. Mail checks & registration to PO Box 4544; Kailua Kona, HI 96745 Any questions? Please contact [email protected] and/or visit www.meetup.com/konamoms. You can also join our Facebook Group by searching for “Kona Moms” on www.facebook.com. Membership dues & registration forms must be received by September 1st, 2014. First meeting is September 16th from 9-11:30 AM. Meetings are bi-monthly from September 16th 2014 to May 26th 2015 on Tuesday mornings from 9-11:30 AM at the Lutheran Church of the Holy Trinity at the bottom of Lako Street in Kona. We will hand out a detailed schedule & calendar of events at the first meeting. Looking forward to seeing you!