Lethbridge Twins & Triplets Club

Box 1532, Stn Main Lethbridge, Alberta T1M 4K2

Membership Application
The

Lethbridge Twins & Triplets Club (LTTC) is a parentssupporting-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
__Club Member
__OB/GYN
(Name)_________________
__Other Medical Referral
____________

__Friend/Word of Mouth
__City Directory/Phone Book
__Internet
__Other (please specify) ____________

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

__No
__No

__Yes
__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:
__New Parents Program/Support
__Adult & Family Socials
__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