Last name:   
First name:  M.I.:
Home phone:    Alternate Phone:  
Address:   
City:  
State:   Zip:

Email Address:

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) and birdate(s):
Name:   Birthdate:
Name:   Birthdate:
Name:   Birthdate:
Name:   Birthdate:

Husband's Name (if applicable):  

MOPS International Membership Fee.....$23.95
St. John's MOPS Fee..................................$54.00

(Payment schedule if dues are not paid in full:  MOPS International fee due at first meeting September 9; St. John's MOPS fee can be paid in two installments: first payment of $27 due by December 9, last payment of
$27 due by April 14, 2011.)