MOPS Online Registration

We accept

Please Note:
You will be transferred to a secure server prior to entering your credit card information.

First Name:	Home Phone	enter as 703-555-1212
Last Name:	Work Phone	enter as 703-555-1212
Spouse's Full Name:
Address:
City:	Email Address
State:	Birthday
Zip:

Name of home church, if any
Interested in infant playgroup?	Yes No
How did you hear about MOPS at IBC?	If "Other" please describe:

CHILDREN INFORMATION: (Up to 4 children may be entered; if more, please fill out form again)
Child 1 Name:		Birthdate:
Child 2 Name:		Birthdate:
Child 3 Name:		Birthdate:
Child 4 Name:		Birthdate:

Select the registration option you prefer:

$40 annual fee. Includes MOPS International membership.
$5 paid at each meeting you attend. With this option, you will not be a member of MOPS International, so you will not receive their special benefits.

After all information has been entered, please click the Continue button.