| Work/Cell Number | |
| Address, City, State, Zip | |
| Birthday | |
| Have you attended a MOPS group before? |
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| If so, where? | |
| Do you attend a church? |
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| If so, where? | |
| How did you hear about this MOPS group? | |
| Are you married? |
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| If yes, husband's name? | |
| What is your anniversary? | |
| Are you expecting? |
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| If yes, due date? | |
| Child in our MOPPETS childcare program: Child's Full Name, Age, Birth Date | |
| Child's special needs and instructions, allergies | |
| Child in our MOPPETS childcare program: Child's Full Name, Age, Birth Date | |
| Child's special needs and instructions, allergies | |
| List homeschool kids that will attend | |
| Emergency Contact Name, Phone | |
| Would you like to receive a newsletter? |
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| Please also list anyone you would like us to send a newsletter to. | |
| What would be your perfect Mom's Night Out? | |
| What is your non-mom career experience, past or present? | |
| What is the most important thing to you about joining MOPS? |
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| I am interested in volunteering on the following committee: |
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