CHAPEL HILL MOPS REGISTRATION

2015-2016

(return completed form to CHPC MOPS, PO Box 829, GigHarbor, 98335)

Questions? Contact Bridget Vandeventer at

Thursdays, 9:30-11:30am

Name:______Date:______

Address:______City/Zip______

Home Phone:______Cell:______

E-mail:______Birthdate:______

Husband’s Name:______

Church Affiliation (not required):______Member?Yes No

How did you hear about MOPS? ______
MOPS is going green! May we notify you by email for all correspondence?YesNo
FEE PAYMENT INFORMATION:

Fall Semester Tuition:$45Due at time of registration to secure your space.

Fall Childcare Cost:$45Due to reserve childcare for 1-2 MOPPETS

Spring Semester Tuition:$30Due in January 2016 for returning moms

$45Due at time of registration for new moms

Spring Childcare Cost:$45Due to reserve childcare for 1-2 MOPPETS

  • To maintain your MOPS registration (including space in Moppets for your children) we kindly ask all fees be paid upon registration. Checks should be made out to “CHPC,” with “MOPS” in the memo line.
  • A once per year MOPS International Registration fee of $25 is included in the first semester registered
  • Childcare cost is for 1-2 children. For 3 or more children, childcare is $90 per semester
  • Limited funds are available for those needing financial assistance. To apply for assistance, a completed assistance request application is necessary by the dates indicated above. Please check here______if you would like a confidential application
  • Registration fees and tuition payments are non-refundable
  • If you’d like to donate $5 to our scholarship fund, check here ______
  • Registration fees and tuition payments are non-refundable
  • If you’d like to donate $5 to our scholarship fund, check here_____

*Please initial the following…

_____I have read the above MOPS fee payment information. I understand that in order to maintain my MOPS registration, my registration fees and semester tuitions must be submitted according to the above schedule. Further, I understand that any requests for financial assistance must also be received according to the above schedule in order to maintain my registration.

PLEASE TURN THIS FORM OVER TO REGISTER CHILDREN IN MOPPETS

CHAPEL HILL MOPPETS REGISTRATION

2014-2015

Mother’s Name: ______

Home Phone:______Cell:______

MOPPETS SERVICE COMMITMENT: In an effort to keep costs down, all moms with children registered in Moppets are required to fulfill ONE Moppets service commitment per semester. You may recruit a spouse, friend, grandparent, etc. to help you fulfill your service commitment. All Moppets volunteers must fill out a WA State Patrol Background check form and turn it in to Tan Jenkins at least one week prior to service date.

*Please initial the following:

_____ I agree to fulfill my MOPPETS requirements by volunteering in Moppets one time per semester (or recruiting someone to do so in my place).

Children TO BE registered in MOPPETS:

Name:GenderDOB:Allergies/Health Issues

______

______

______

If pregnant, due date:______# children if multiple birth______

Please indicate any special circumstances regarding your child(ren) of which we should be aware:

Other children, that will NOT be registered in Moppets:

Name:DOB:

______

______

______

PHOTO AUTHORIZATION

Photos may be taken during MOPS/MOPPETS events for inclusion in Chapel Hill/Chapel Hill MOPS publications or promotional materials. Please complete the following information for the children you are registering in MOPPETS (named above):

I, ______(parent or guardian) give my permission for my child(ren) (named above) to have his/her photo taken in Chapel Hill/Chapel Hill MOPS publications or promotional materials. I also give permission for my photo to be taken for use in Chapel Hill/Chapel Hill MOPS publications or promotional materials.

Signature: ______Date:______

GROUP PLACEMENT

We make every effort to place people in groups according to what they are hoping to get out of MOPS. Please read the statements below and circle the TWO that mostly apply to you:

  1. I am new to GigHarbor and want to meet people.
  1. I am a first time mom and want to have fellowship with other first time moms.
  1. I want to learn more about being a mom from other moms/mentor moms.
  1. I look forward to great guest speakers and learning new things about being a mom/parenting.
  1. I am looking for play dates and fellowship with moms of similar aged children.
  1. I am looking for play dates and fellowship with moms and other children, no necessarily similar aged children.
  1. I am hoping to make new mom friends to have Ladies Nights Out without children.
  1. I look forward to MOPS meetings in order to have kid-free time with other moms.
  1. Other:______