Registration

You may register at any time during the summer for the fall semester.  Please click here to access the Registration Form, or copy and paste the below form into an email and send it to valleyspringsmops@gmail.com

   

   

2014-2015 MOPS International

Registration Form

Welcome to MOPS! Please complete this form so we can learn some basic information about you.

Last Name: ________________   First Name:____________  M.I. ___

Home Phone: ________________  Alternate Phone: ______________

Address: _________________________________________________

City: ___________________   State: _____  Zip code: ___________

Email: __________________________________________________

Birthday: _____________________

What is the best way to contact you?  ⃞ Email  ⃞ Phone

Home church (if applicable):_______________________________________________

Husband’s Name (if applicable):_______________________________________________

How did you hear about this MOPS group?_______________________

Please list your child(ren)’s name(s) and birthdate(s):

Name: _______________________ Date of Birth: _______________

Favorite toys, songs, games: _________________________________

Special needs/instructions (allergies): __________________________

Name: _______________________ Date of Birth: _______________

Favorite toys, songs, games: _________________________________

Special needs/instructions (allergies): __________________________

Name: _______________________ Date of Birth: _______________

Favorite toys, songs, games: _________________________________

Special needs/instructions (allergies): __________________________

Name: _______________________ Date of Birth: _______________

Favorite toys, songs, games: _________________________________

Special needs/instructions (allergies): __________________________

Who has permission to pick up your child(ren) in case of emergency?

Father – Name: _________________________  Phone: ___________

Relative – Name: _________________________  Phone: __________

Other – Name: _________________________  Phone: ___________

Family Doctor

Name: _________________________ Phone: ___________________

Address: _________________________________________________

Additional Emergency Contact

Name: _________________________ Phone: ___________________

Address: _________________________________________________

Total…………………………………………………………………$85.00

Payment may be made in the follow ways:

           Cash

Check - made out to Valley Springs Presbyterian Church with    

             MOPS in the memo

          Credit Card Payment – Go to this link and follow the instructions.

          Scholarships/Payment Plans – Please email us at

                  valleyspringsmops@gmail.com for more information.

For MOPS Group Use Only

Date registration received:

Discussion Group assigned:

Date registered for MOPS International Membership:

Print and return or copy and paste into your email and send to valleyspringsmops@gmail.com