Application for Membership Families with Children from China - New England Membership level: Family ($35) ........ Friend ($50) ........ Patron ($100) ........ Benefactor ($150) Renewal (if renewal, please fill in name, city and any new or changed information) Contact information:
			[spouse or additional contact info - if needed]
First Name:			First Name:
Last Name:			Last Name:
Address:			Address:
Address 2:			Address 2:
City:			City:
State:			State:
Zip code:			Zip code:
Home Phone:			Home Phone:
Work Phone:			Work Phone:
Email:
Email:(confirm)
Email2:
Email2:(confirm)
(note that USPS mail will only be sent to primary address)
Do you wish to be included in the FCC-New England Directory? Yes No (The Directory includes both adoptive and waiting families, and is distributed to individual members for personal use only. Some waiting families prefer to wait until after their adoption to be listed.) Please check if you are willing to receive event notices only via email instead of USPS mail (China Connection and our directory are always sent via USPS mail) Please check if you are: .... Adoptive Family .... Waiting Family .... Friend Please check if you are interested in volunteer opportunities with FCC-NE: Please check if you would like us to withhold your name if we share our mailing list (In rare circumstances, the FCC-NE board may vote to share its mailing list with organizations which might be of interest to its members.) Comments:
Information on each of your children (please include all of your children for our directory): First Name Last Name Date of Birth Date of Joining Family Facilitating Agency Orphanage Name - Province - Country - Birthchild
Please review your information carefully. Note that membership application is not complete until credit card information is processed.