Registration Form
Welcome to the VCC MOPS! Please complete this form so that we can learn some basic information about you.
Last name: _____________________________First name: ____________________________M.I.:______
Home phone:_____________________________________Work phone: ___________________________
Address: ______________________________________________________________________________________
City: ________________________________________State:______________________ Zip: __________
Birthday: _______________________E-mail: ________________________________________________
Have you attended a MOPS group before? ❏ Yes ❏ No
If so, where? ____________________________________________________________________________________
How did you hear about this MOPS group__________________________________________________
Please mark which area of the VCC MOPS that you would like to be involved in:
❏Coordinating ❏Hospitality
❏Creative Activities ❏MOPPETS
❏Discussion Group ❏Mentor Mom
❏Finance ❏Publicity
Would you be able to help provide childcare for our monthly Steering Team meetings? ❏ Yes ❏ No
Please list at least one person you know who might be able to be a teacher or a helper for our MOPPETS:
______________________________________________________________________________________
Are you registered for the MOPS to Mom Connection through MOPS International? ❏ Yes ❏ No
Do you attend a church? ❏ Yes ❏ No
If so, where? ______________________________________________________________________________________
Please list your child(ren)’s names and birth dates:
Name: _____________________________________________Date of birth: ________________________
Name: _____________________________________________Date of birth: ________________________
Name: _____________________________________________Date of birth: ________________________
Name: _____________________________________________Date of birth: ________________________
Husband’s name (if applicable): ________________________ Anniversary: ________________________

For MOPS Group Use Only:
Date registration received: __________________________________________________
Date registered for the MOPS to Mom Connection:_____________________________
Discussion Group assigned: _________________________________________________