Lethbridge Twins & Triplets Club

Box 1532, Stn Main Lethbridge, Alberta T1M 4K2

Membership Application

The Lethbridge Twins & Triplets Club (LTTC) is a parents-

supporting-parents
group, dedicated to improving and promoting the health and well being of
multiple birth families during and beyond pregnancy.

Membership fees are $30.00 for one year and are to be paid by September of the current
membership year. Thank you in advance for completing the form below. Please feel free to
contact the members of the LTTC Executive should you have any questions or concerns
regarding membership. We can also be reached through our website
www.lethbridgetwinsandtriplets.bravehost.com for links to resources, information and
association activities.

Email: lttc_mail@yahoo.ca

Membership Fees: Date:___________

From September 5, 2007 – September 2, 2008
$25.00 if paid b4 Sept. 5th, 2007
$30.00 if paid on or after Sept. 5th, 2007______Cheque ______M.O. ______Cash _______Fundraising
Exempt

Please make cheques or money orders payable to: Lethbridge Twins & Triplets Club.

Personal Information:
Mother’s Name __________________________________________ D.O.B.___________________
Father’s Name __________________________________________ D.O.B.___________________
Anniversary ___________________
Address : ______________________
City/Town ______________________
Postal Code ______________________

Phone Number: ______________________ Cell Number: ______________________

Work Number:______________________ Other ______________________
Email Address: __________________________________________

Expected or Actual Date of Delivery of Multiples: ____________________________________

Names: __________________________________________________________________

Pregnancy, Birth weights & Gestation of Your Multiples

At what gestation were your multiples born? _____________ weeks _______days

What were your multiples’ birth weights (Pounds & ounces)?

Baby A: __________ B: _________C: _________

NICU Time:
Baby A: __________ B: _________C: _________

Type of Multiples: (B - boy; G - girl)

Twins: __BB __GG __BG

Triplets: __BBB __GGG __BBG __GGB

__Identical __Fraternal __Fraternal & Identical __Unsure

List additional children's names, genders and birthdates:
Name B/G D.O.B. Name B/G D.O.B.
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________

What would you like to get out of the club this year? Please give details if
possible.
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

LTTC QUESTIONNAIRE
In order to better understand the needs of our members, we are asking that you complete
the following questionnaire. This data will be kept confidential for the use of general
statistical information only. Thank you for participating.

Where did you hear about LTTC?

__Advertisement __Friend/Word of Mouth
__Club Member __City Directory/Phone Book
__OB/GYN __Internet
(Name)_________________ __Other (please specify) ____________
__Other Medical Referral
____________

Breastfeeding/Bottle-feeding Support
Would you like to be contacted by our Breastfeeding Support Coordinator? __No __Yes
Are you planning on bottle-feeding? Would you like to be contacted for support? __No __Yes

The club has breastfeeding pillows to lend and breast pumps to rent.

VOLUNTEER INTERESTS
LTTC is totally run and operated by Volunteer Club Members. Any volunteer contribution you
can give makes a difference toward the success and longevity of our Club. Volunteering is a
rewarding experience! Help assure your club is what you want it to be.

Would you like to volunteer?

__Yes __Not Yet

Which areas of LTTC are you most interested in being involved with:
__Adult & Family Socials __New Parents Program/Support
__Other/Misc. Project
__Breastfeeding Support
__Executive/Administrative
Is there anything specifically you would like to be involved in?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____
Photo & Information Release - We respect your privacy; therefore we require your
approval to release your information (such as names, birthdates) and photos in the LTTC
database. This information will only be accessed by current LTTC members. Photos may also
be used on our website & in promotional materials. Please indicate your approval by signing:
___________________________
Member Signature