MOPS REGISTRATION FORM

Grace Fellowship 2009-10

_______Seifert_______________________________
____Rachel_____________________________________
Last Name
First Name
__8308 Emery Parkway
N____________________________________________________________________________________
Address
_Champlin_______________________________________MN______________________55316______________________
________
City
State
Zip Code
__763-432-9309_________________________________________ _763-2137422_____________________________________________
Home Phone Number
Cell Phone Number (if applicable)
_08/10/86______________________________________ _
________rach.seifert@gmail.com_______________________________
Birthdate
email Address
Prior MOPS attendee?
Yes
No
_______________________________________________
Do you attend a church?
Yes
No
Free___________________________________

Where?

Where?_____Maple Grove Evangelical

How did you hear about MOPS?

___Friends__________________________________________________________________
Husbands Name:
__Matt________________________
Date:_08/31/08_____________________

Anniversary

(if applicable)

Childrens Names:

(those who will attend MOPPETS)

Name ___Noah_______________________

Birthdates:
___11/5/10_____________

Special Info: (allergies, etc.)

________________________________

Name _____________________________ ___________________

________________________________

Name _____________________________ ___________________

________________________________

New Arrival? _____________________________ ___________________

________________________________

Other Children

(those NOT attending MOPPETS):

Name / BD ______________________
____________________

Name / BD _____________________ Name / BD

Please mark your 1st & 2nd choices for group session preferences (1 for 1st choice, 2 for 2nd
choice):
(2nd & 4th) Mondays 9:30-11:30 ___1st____________
(2nd & 4th) Tuesdays 9:30-11:30 ___2nd______________
*Group assignments are made on a first come, first served basis
*$50 semester fee due at first meeting, to cover group costs

Send completed form with $23.95 nonrefundable registration fee (payable to Grace
Fellowship MOPS) to:
*registration fee goes directly to MOPS International*
For Monday group, mail to:

For Tuesday group, mail to:

Kimberly Anderson
9921 Toledo Dr. N
Brooklyn Park, MN 55443
763-424-9921
kim@joelandkim.net

Miranda Anderson
1148-C 100th Ave NE
Blaine, MN 55434
763-795-0396
miranda_anderson@hotmail.com

For Steering Use Only

Date
Registration

________

Amount
________

Check #
_______

1st Semester

_________

_________

________

2nd Semester

_________

_________

________

Discussion Group ____________________________