2013-14 MOPS International Early 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), birthdate(s) and if they will be attending MOPPETS:
Name: _______________________________________ Date of Birth: ________________________ Yes / No
Name: _______________________________________ Date of Birth: ________________________ Yes / No
Name: _______________________________________ Date of Birth: ________________________ Yes / No
Name: _______________________________________ Date of Birth: ________________________ Yes / No
Husbands Name (if applicable): ____________________________________________________________________

MOPS Spring Membership Fee (before May 31, 2013)... $21.95

(Includes MomSense Magazine, Weekly Mom-E-Mail, a MOPS Reusable Shopping Bag, MOPS Bookmark & Magnet and
Exclusive Access to MyMOPS Online)

Group Support (optional) This donation helps support the local Owatonna MOPS group providing
financial means to facilitate speakers, MOPPETS workers, creative activities, etc. Please consider helping
this local ministry as you are financially able.
__ $10
__ $25
__ $50
__ Other $_____ . $_____
Total .. $_____

For MOPS Group Use Only

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

Copyright 2012 MOPS International, Inc