I want to register for MOPS Session 1 2008-2009
September 9, 2008 through January 27, 2009

Mom's Name (First and Last Names, please):       

Mom's Birth date    Month: select month January February March April May June July August September October November December   Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year:  

Address:

City:   State:   Zip Code:

Home Phone:   Cell Phone:

E-mail Address:

Home Church:

Are you a returning MOPS mom from 2007-2008? select one Yes No

In what areas would you be interested in helping? (select as many that apply):
  Hospitality Creative Activities Fundraising Discussion Groups No, thank you

CHILDCARE: There may be a waiting list for childcare - if so, you will be notified immediately.

Do you need childcare? select one Yes No If no, skip down to "Session #1 Fees"

If yes, please complete the following information for your children who will be in childcare:

Child 1 Name:   Birthdate Month: select month January February March April May June July August September October November December   Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year: 2002 2003 2004 2005 2006 2007 2008 2009 Allergies? Yes No   Boy/Girl? Boy Girl

Child 2 Name:   Birthdate Month: select month January February March April May June July August September October November December   Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year: 2002 2003 2004 2005 2006 2007 2008 2009 Allergies? Yes No   Boy/Girl? Boy Girl

Child 3 Name:   Birthdate Month: select month January February March April May June July August September October November December   Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year: 2002 2003 2004 2005 2006 2007 2008 2009 Allergies? Yes No   Boy/Girl? Boy Girl

Child 4 Name:   Birthdate Month: select month January February March April May June July August September October November December   Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year: 2002 2003 2004 2005 2006 2007 2008 2009 Allergies? Yes No   Boy/Girl? Boy Girl

Child 5 Name:   Birthdate Month: select month January February March April May June July August September October November December   Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year: 2002 2003 2004 2005 2006 2007 2008 2009 Allergies? Yes No   Boy/Girl? Boy Girl

If your child has allergies, please indicate which child and their allergies below:

Names of adults who can pick up your child(ren)?

Names of other children/siblings NOT in MOPS childcare:

SESSION #1 FEES:

Mom's meeting fees: 9 meetings for Session #1 @ $4.00 per meeting
Childcare fees: 9 meetings for Session #1 @ $3.00 per child per meeting (max to pay for is four children)
MOPS International Registration Fee: $23.95 annual fee

Mom's Meeting Fees: select one Returning Mom = $36.00 (9 meetings @ $4.00 per meeting) NEW Mom = $32.00 (8 meetings @ $4.00 per meeting - first meeting FREE!)

Childcare Fees: Select one No childcare needed One (1) Child = $27.00 (9 meetings @ $3.00 per child per meeting) Two (2) Children = $54.00 (9 meetings @ $3.00 per child per meeting) Three (3) Children = $81.00 (9 meetings @ $3.00 per child per meeting) Four or more (4+) Children = $108.00 (9 meetings @ $3.00 per child per meeting - max 4)

MOPS International Registration Fee: $23.95 - one-time annual fee I am already registered with another MOPS group

IMPORTANT NOTES:

• If you are planning to attend more than 2 meetings this session, you must register for the ENTIRE session to reserve a childcare spot.

• 50% Total Amount due at registration, balance due by first meeting unless payment plan arranged.

• Fees are non-refundable.

• If you are applying for a scholarship, you MUST print the form and send it in for it to be considered.

• You must confirm your registration below by clicking on the box below in order for your registration to be accepted.

By checking this box, I understand and agree that completing and sending this Registration Form acknowledges a commitment to make all required payments as selected above.