MOPS @ LCC Registration 2018-2019
Please fill out this form and click submit.
Your Contact Info
Name
*
Email
*
This address will receive a confirmation email
Phone
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Birthday
*
Your MOPS Info
Are you currently part of a MOPS group (besides LCC)?
Please select one option.
Yes
No
If yes, where?
Home Church (if applicable):
How did you hear about this MOPS group?
Your Family Info
Please list your child(ren)'s name(s) and birthdate(s)
Husband's name and birthdate (if applicable)
MOPS is $100 for the year, or $40 per semester and $32 for the MOPS, International Dues. If you would like your spot saved, please pay $32. If this presents a financial burden, please choose the last option and we will reach out about our scholarship opportunities. DUE TODAY:
$32: SAVE MY SPOT! $40 due 9/13 and 2/14. ($32)
$72: Dues and 1st Semester ($40 due 2/14): ($72)
$100: The Whole Year: ($100)
$0: Please contact me about partial scholarships or a payment plan: ($0)
$32: SAVE MY SPOT! $40 due 9/13 and 2/14. ($32)
$72: Dues and 1st Semester ($40 due 2/14): ($72)
$100: The Whole Year: ($100)
$0: Please contact me about partial scholarships or a payment plan: ($0)
Amount
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
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