Steering Use Only
PAID:
cash $__________
check #__________
Mother’s Registration Form
CROSSROADS PRESBYTERIAN CHURCH 2014-2015
Mom’s Info:
Last name: _____________________________________
First: _______________________________
Address: ______________________________________
City: ________________ Zip: ____________
Cell phone: ____________________________
Home phone: ___________________
E-mail: ______________________________________
Birth Date: _____________________________
Husband’s Info (if applicable):
Husband’s Name:____________________________
Husband’s Phone: _______________________
Wedding Anniversary Date:_____________________
Do you have a home church?
Yes
No
If yes, where?___________________________________
Have you ever been involved with a MOPS group other than at Crossroads?
Yes
No
If yes, where? ___________________________________
Please list names and birth dates of your children: (please  those children who will be attending with you.)
Name:_____________________________________________
Birthday: ____/____/____
Name:_____________________________________________
Birthday: ____/____/____
Name:_____________________________________________
Birthday: ____/____/____
Name:_____________________________________________
Birthday: ____/____/____
Name:_____________________________________________
Birthday: ____/____/____
Please also fill out the “MOPPETS Registration Form” for your child(ren) attending the MOPPETS program.
(OVER)
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Giving of Your Time and Talents
MOPS is for Moms, by Moms. We ask each mom to participate on one committee as she is able.
Please check the areas you would be willing to serve.
____
Meeting Set-up: arrive 30 minutes early to help set up for the meeting.
____
Meeting Clean up: stay after the meeting to help put away table items etc.
____
MOPPETS: help classroom set-up before meetings and clean-up after, help prepare children's craft
activities and lesson plan materials prior to meetings
____
Care Team: assist moms in our MOPS group. Plan meals or help for a mom whose family has just
welcomed a new addition or faces illness, death, or other crisis - one leader per table is needed
____
Publicity: assist with the bulletin board, taking photos at meetings, distributing flyers, etc.
Fee Info:
We will be charging per semester for the 2014-2015 MOPS year. Payments are due at the beginning of each
semester. Members also have the option of making one payment for the entire year.
There is an annual registration fee required by MOPS International. This fee registers and recognizes
membership in MOPS International. You will receive weekly emails, a book bag and the bi-monthly magazine
“MomSense”. The registration fee must be paid by all members regardless of the date a member joins MOPS.
The MOPS International dues are $25 for the year, and the semester dues are $40 each semester.
**Confidential Financial Assistance is available. Prospective members and members are encouraged to speak with
Finance Coordinator, Laura Peyton, about any concerns they have or assistance they may need regarding
payment of dues. Contact Laura at (517) 290-3476 or [email protected].
Please check the payment option(s) you are enclosing with this form:
$25 MOPS International Membership fee* (required of all members)
$40 First Semester dues (due at first September meeting)
$40 Second Semester dues (due at first January meeting)
$ __________ TOTAL payment enclosed
DATE:____________________________
Please, make checks payable to Crossroads.
Please return all forms along with your payment to:
MOPS Finance Coordinator
Crossroads Presbyterian Church
6031 W Chapel Hill Road
Mequon, WI 53097
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MOPPETS Registration Form
CROSSROADS PRESBYTERIAN CHURCH 2014-2015
(Please only list children who will attend. Attach a separate sheet for any additional
children)
Child’s First name: __________________________ Last:__________________________ Birth date: ____________
Circle Preschool Grade Enrolled in Fall:
N/A
Allergies: No Yes (please list)__________________
3K
4K
5K
Toilet-Trained Yes No
Snacks okay? No Yes
Please list any helpful information (custody concerns, things that comfort such as pacifiers or being held a certain way, etc.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Child’s First name: __________________________ Last:__________________________ Birth date: ____________
Circle Preschool Grade Enrolled in Fall:
N/A
Allergies: No Yes (please list)__________________
3K
4K
5K
Toilet-Trained Yes No
Snacks okay? No Yes
Please list any helpful information (custody concerns, things that comfort such as pacifiers or being held a certain way, etc.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Child’s First name: __________________________ Last:__________________________ Birth date: ____________
Circle Preschool Grade Enrolled in Fall:
N/A
Allergies: No Yes (please list)__________________
3K
4K
5K
Toilet-Trained Yes No
Snacks okay? No Yes
Please list any helpful information (custody concerns, things that comfort such as pacifiers or being held a certain way, etc.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Mother’s/Guardian’s Information
First name: __________________________
Home phone: __________________
Last: _________________________
Cell Phone: __________________ Email: ________________________________
Additional Emergency Contacts: Name: __________________Phone: __________________Relationship: ___________
Name: __________________Phone: __________________Relationship: ___________
As the parent/guardian of the above named child(ren), in the event that I am unavailable, I hereby empower and grant to the MOPS/MOPPETS
program of Crossroads Presbyterian Church permission to consent to and authorize medical and hospital care and treatment for the above named
child(ren):
Physician’ Name: ____________________________________
Office Phone: _______________________________
This authorization shall be valid for the period of time beginning on September 1, 2014 and ending on May 30, 2015.
Mother/Guardian Signature:_____________________________________________Date__________________________
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Photography Release
Permission to use child’s image, name and/or organization.
I, ______________________________, am the parent or guardian of ___________________________________.
(Print Parent/Guardian’s Full Name
(Print Name(s) of Child(ren)
I hereby grant the MOPS group of Crossroads Presbyterian Church (MOPS), permission to use photographic,
video, and digital images as indicated below on the Crossroads MOPS facebook page, church website and bulletin
board.
PHOTO / IMAGE ONLY of my child.

PHOTO / IMAGE ONLY of my child with the ORGANIZATION NAME (Crossroads MOPS)

PHOTO / IMAGE of my child with the CHILD’S NAME and the ORGANIZATION NAME (Crossroads MOPS)
Permission to use adult’s image, name and/or organization.
I, ______________________, am the parent or guardian of _________________________________.
I hereby grant the MOPS group of Crossroads Presbyterian Church (MOPS), permission to use photographic,
video, and digital images as indicated below on the Crossroads MOPS facebook page, church website and bulletin
board.
PHOTO / IMAGE ONLY of my child.

PHOTO / IMAGE ONLY of my child with the ORGANIZATION NAME (Crossroads MOPS)

PHOTO / IMAGE of my child with the CHILD’S NAME and the ORGANIZATION NAME (Crossroads MOPS)
By signing this, I hereby release the MOPS Group and Crossroads Presbyterian Church, its units, councils,
districts and its legal representatives from all claims and liability relating to said photographs, video and digital
images.
Parent/Guardian/Adult Signature: _________________________________________ Date: _________________
Parent/Guardian/Adult Printed Name:
_____________________________________________________________
Address, City, Zip:
____________________________________________________________________________
Telephone: ____________________________________ Email: _______________________________________
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