2012-13 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: _____________________
Have you attended a MOPS group before? Yes No
If yes, where? __________________________________________________________________________________
Are you registered for the MOPS International Membership? Yes No
Home church (if applicable): _______________________________________________________________________
How did you hear about this MOPS group? ____________________________________________________________
Please list your child(ren)s name(s) and birthdate(s):

Please check if they will be attending MOPPETS:

Name: ____________________________________________________ Date of Birth: ______________

____

Name: ____________________________________________________ Date of Birth: ______________

____

Name: ____________________________________________________ Date of Birth: _______________

____

Name: ____________________________________________________ Date of Birth: ________________

____

Husbands Name (if applicable): ____________________________________________________________________

Registration Fee for Fall.$60.00

(Includes MOPS International Fee and Calvarys Fall Semester Fee)
OR

Registration Fee for the ENTIRE Year

.$90.00

(Includes MOPS International Fee and Calvarys Fall and Spring Semester Fees)
Please Mark Selection:

__I am paying for the Fall semester only. $60.00 Cash__ or Check#__
__I am paying for the Entire Year.

Please make checks payable to Calvary MOPS.

For MOPS Group Use Only

Date registration received:
Discussion Group assigned:
Date registered for MOPS International Membership:

Copyright 2011 MOPS International, Inc

$90.00 Cash__or Check#__