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
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