Please Check the Appropriate Box for spring 2016


Last Name*

First Name*

Husband's Name


Address

City

Zip


Home Phone (ex. (516) xxx-xxxx)

Cell Phone (ex. (516) xxx-xxxx)


E-Mail Address


Are you on Facebook?


Emergency Contact Name

Emergency Contact Phone Number


Birthday


Moppets (Children Participating)
Name (child1)

Birthday (child1)


Name (child2)

Birthday (child2)


Name (child3)

Birthday (child3)


Do you attend church?
YesNo
If yes, where? What is the name of the church?


How did you hear about MOPS?

Special Needs and Instructions; Allergies:

Any questions, contact Blessing Chiu at 917-553-7474

REGISTRATION & LATE FEE POLICY

  • Regular Registration Fee: $85 for 1 semester
  • For Fall 2016, sign up for the whole year and save $20. More details later.

  • Please make checks payable to NHPBC, write "MOPS" in memo and mail to:

    New Hyde Park Baptist Church
    635 New Hyde Park Rd; New Hyde Park, N.Y. 11040