MOPS - Mothers of Preschoolers, Crossroads 2015 - 2016 Registration Form

Welcome! Please complete this form so we can learn about you!

Last Name

First Name

M.I.

Home Phone

Alternate Phone

Address

City

State

Zip Code

Birthday

Email

What is the best way to contact you?

Email

Phone

Have you attended a MOPS group before?

Yes

No

If yes, where?

Home Church (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

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

***Please Specify child's special needs / allergies if any***

Special needs / allergies

Husband's Name (if applicable)

Emergency Contact (name and phone)

MOPS Membership Fee, Fall Semester, Sept. - Dec. ............$35

MOPS Membership Fee, Spring Semester, Feb. - May ..........$35

MOPS Membership Fee, BOTH SEMESTERS ......................$50

***All registration fees are non-refundable***

Make checks payable to: Crossroads Bible Church

Send checks to: 144 Appleton Rd, Elkton, MD 21921

ATTN: MOPS

Success! This form has been submitted. Thank You