HMN Membership Registration
Please complete the form below and click the Submit button to complete your membership, paying by credit card or using a PayPal account. Registration will not be complete until payment information is entered and a notification of payment is received from PayPal. Please complete the entire process, including online payment, to obtain your HMN Membership.

Fields marked R are required.
First Name R
 		Last Name R
Primary E-mail Address R
 		Alternate E-mail Address
Address 1 R
 		Address 2
City R
 		State R
Other State
 		  Zip R
Country R
Home Phone R
 		Work Phone
Cell Phone
 		County R
Chapter R
Membership Type R
Additional Donation to HMN
$
Coupon Code
 
Chapter Leader/Co-Leader ($35 One-Time Fee)
Renewal
I am interested in volunteering
Members will be invited to their local Chapter Email Loop. Please check here if you would also like to join our HMN National Email Loop.
Membership in Second HMN Chapter in addition to Chapter listed above...
($25 or $30 for Individual or Family, respectively)
Comments
Please take a moment to tell us about yourself, so we can better tailor our Holistic Moms Network programs to suit your needs.
Your Age R


Your Gender R


Number of Children R


Practitioner? R


If Yes, Profession

Other Profession
 		Which activities are you involved with?
(Check all that apply)
Meetings
Playgroups
Email Loop
Annual Conference
Outings
Support Network
Co-op
Fundraising
Other:
How old are your children?
(Check all that apply)
No Children
Newborn - 2
3 - 5
6 - 10
11 - 18
Over 18
 		When do you attend meetings?
(Check all that apply)
Daytime
Evening
Weekdays
Weekends
What are your areas of interest?
(Check all that apply)
Healthy Eating/Organic Food
Alternative Health
Breastfeeding
Natural Childbirth
Stress Reduction/Exercise
Vaccination
Holistic Education
Environment
Sleep Issues
Attachment Parenting
Fighting Consumerism
Spirituality
Parenting Multiples
Political Activism
Other:
How did you hear about HMN?
(Check all that apply)
Email
Flyer
Mothering Magazine
Internet Search
Member Referral
Facebook
Mailer
News/Media
Other:
 
HOLISTIC MOMS NETWORK PO BOX 408, Caldwell, NJ 07006 Phone: (877) HOL-MOMS Email: INFO@HOLISTICMOMS.ORG