Registration Form 2017-2018


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Registration Form 2017-2018 Welcome to MOPS! Please complete this form so that we can learn some basic information about you. Also Keep in mind early registration is the only way to guarantee yourself a daycare spot for next year. First Name:_________________________________ Last Name:_____________________________________ Address:____________________________________________________________________________________ City:________________________________________State:__________________________ Zip:_____________ Preferred Phone:_________________________________ Email:____________________________________________Birthday:____/____/____ Anniversary:____/____/____ Have you attended a MOPS group before? ❏ Yes ❏ No If so, where? ________________________ Do you attend a church? ❏ Yes ❏ No

If so, where? _______________________________________

How did you hear about this MOPS group? ___________________________________________________ Please list your child(ren)’s names and birth dates: Name: ____________________________Date of birth: ______________________ Will they be attending MOPS childcare? Yes ______ No_______ Allergies___________________ Name: ____________________________Date of birth: ______________________ Will they be attending MOPS childcare? Yes ______ No_______ Allergies___________________ Name: ____________________________Date of birth: ______________________ Will they be attending MOPS childcare? Yes ______ No_______ Allergies___________________ Name: ____________________________Date of birth: ______________________ Will they be attending MOPS childcare? Yes ______ No_______ Allergies___________________ Husband’s name (if applicable): _________________________________________________________________ Would you be willing to donate $3 or more towards a MOPS scholarship for a mom in need? Yes___No____ (Add a mount below. Registration Options: (Please make checks payable to HCC) In need of a scholarship please contact Amanda McLellan. ❏ Yearly fee with children $90 ❏ Yearly fee without children $75 ❏ Yearly fee $25 plus $5 at each meeting

Payment Calculator: Registration option:________________ + Scholarship for mom in need_______________= Total Due:_________ For MOPS Group Use Only: Date Registration Received:_________ Date Registered for MOPS to Moms Connection:_______ Discussion Group Assigned:___________________ Added to Email list:________________________