MOPS Registration

Each mom in our MOPS group is asked to complete a registration form each year. This information is used to register each mom with MOPS International and helps us get to know each other better. No personal information will be shared outside of this group. Registration fees are $30/semester (twice/year) or $55/year and can be paid at a meeting. Scholarships are also available. Thank you for your interest in Living Hope MOPS, we look forward to growing as moms with you!

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Home Phone:

Cell Phone:

E-mail Address: *

Birthday (Month & Date): *

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?: *

Would you like more information about MOPS scholarships?: *

YES

NO

Please list your children's names and birthdates and if they will be needing childcare during meetings.

Child's Name 1:

Child's Birthday 1:

How often will child #1 need childcare during meetings?:

Never

Sometimes

1st Mondays

3rd Mondays

All Meetings

Child's Name 2:

Child's Birthday 2:

How often will child #2 need childcare during meetings?:

Never

Sometimes

1st Mondays

3rd Mondays

All Meetings

Child's Name 3:

Child's Birthday 3:

How often will child #3 need childcare during meetings?:

Never

Sometimes

1st Mondays

3rd Mondays

All Meetings

Child's Name 4:

Child's Birthday 4:

How often will child #4 need childcare during meetings?:

Never

Sometimes

1st Mondays

3rd Mondays

All Meetings

Child's Name 5:

Child's Birthday 5:

How often will child #5 need childcare during meetings?:

Never

Sometimes

1st Mondays

3rd Mondays

All Meetings

Husband's Name (if applicable):

Consent to Use Photos

As participant of MOPS and a parent/guardian of the child(ren) listed above, I give permission to Bloomington Living Hope Lutheran to publish for its own use any pictures of myself or my child(ren) taken during this program.

Consent Granted?: *

YES

NO