2016-2017 Newberg MOPPETS Registration
**8/18/16 UPDATE: Our MOPPETS program is currently FULL. At this time moms are welcome to continue to join us, however they will need to find their own childcare. Babies under one years of age can stay with the mom during the meeting as a lap baby. If you wish to wait list your child(ren) for MOPPETS, please complete this form. **

If you have children who will be attending the MOPPETS program, please fill out this form. A form will need to be completed for each child.

Child's Last Name:
Your answer
Child's First Name:
Your answer
Preferred Name:
Your answer
Gender:
Birthday: (mm/dd/yy)
Your answer
Mother's Name:
Your answer
Best Phone Number for Mother:
Your answer
Father's Name:
Your answer
Best Phone Number for Father:
Your answer
Does the father live at home?
Child's Doctor:
Your answer
Doctor's Phone Number:
Your answer
Emergency Contact Name:
Your answer
Emergency Contact Phone Number:
Your answer
Emergency Contact's Relationship to Child:
Your answer
Siblings: (names & birth dates)
Your answer
Favorite toys, songs, games, foods - please be specific:
Your answer
Special needs, allergies or instructions:
Your answer
Please choose one of the following: (answer thinking of September)
I give permission for my child to be photographed/video taped while in the MOPPETS program to be used for MOPS only. (Your typed name below counts as your electronic signature.)
Your answer
Submit
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