Please complete the application below and click submit. Your application will be reviewed and, upon acceptance, added to the list within 24 hours of receipt. The information given below qualifies individuals for participation in the mailing list. This information will never be released or sold to any individual or company. It is needed to ensure that only individuals who are interested in the Pregnant At Last Society are admitted to this online support group. Thank you. BEFORE YOU SUBMIT Please recheck your e-mail address to ensure it is accurate. If we do not receive the correct e-mail address, it will be impossible for us to contact you to let you know that the server cannot reach you.

Name

First  Last

Email

(confirm email)

Create the password that you want to use to access the list Archives and Account Management website.

Age

20-25 26-30 31-35 36-40 41-45 46-50 50+

How long have you experienced fertility problems?

Never 1-2 years 2-3 Years 3-4 Years 4-5 Years 5+ Years

Please provide a brief overview.

What was the date of the transfer that led to this pregnancy, or your last menstrual period (please note which it is)?

Have you had an ultrasound and seen the hearbeat?

Yes No

If not, when are you scheduled to do so?

How many babies are you expecting?

Boys Girls  Due Date (If Known)

Your Location:

City  State/Province Country

Please let us know how the On-Line Support Group can help you:

You may choose how you would like to receive the list messages.

Individual messages as they are generated Digest - One email per 24hr period containing all of the messages from that day

How did you hear about us?

I agree to abide by the Rules of Conduct  to retain my privilege to participate in this online support group. I understand that if I violate any of these rules, I may be unsubscribed, without warning, to protect the best interest of the group.