LEEAF Registration Form  Today's date ___/___/___

          (For renewals and new LEEAF members.  Please print this form and mail to the address below.)     

*Please check here if this is a change of address ______       

Name _________________________________________________

Address________________________________________________

Phone #_______________ E-mail Address____________________

Children     

1.  Name _________________ Date of Birth _________ Date of Adoption_________

   

     Country _______________ Region _______________ Agency_______________

2.  Name _________________ Date of Birth _________ Date of Adoption__________

     Country _______________ Region_______________ Agency _______________

___Yes, please match me with a mentor family to help guide me

    through the adoption process and offer support.

    I would like to be matched with a family that has:

       __ adopted an infant/toddler

       __ adopted an older child    __ single parent    other __________________________

    Name of agency ___________________ Homestudy agency ____________________

___ Yes, I am interested in becoming/remaining a mentor family.

___ I am interested in organizing/leading future shoe/backpack drives for Russian orphanages in my parish, workplace or church.

___ I am interested in having a smaller, local/church fundraiser to raise funds to help          Russian orphans.

___ Yes, add me to the LEEAF agency registry to act as a reference for my agency.                  (Please do not check if you are already listed on the website's agency registry.)

___Yes, I would like to be included in the Baton Rouge area activities and play dates (For      Baton Rouge and immediate surrounding area families).

___ Yes, I am interested in helping with a LEEAF event (set up or clean up).

LEEAF is not an incorporated entity and I/we, _________________________________________________,

agree not to hold any of the LEEAF steering committee members personally liable in the event of injury at a LEEAF event.

How did you first learn about LEEAF? _______________________________________

Please enclose your $35/yearly membership donation fee, made payable to LEEAF, to be utilized toward LEEAF events/meetings, education, LEEAF website fees, orphanage and orphan support, and other administrative needs.

MAIL TO:  Karen Bordelon, 916 Rue Chartes, Mandeville, LA 70471