Evangelical Free Church of Libertyville

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REGISTRATION

If you are interested in registering for the MOPS program at the Evangelical Free Church of Libertyville, please complete the online form below. Your information will be sent to a member of the MOPS leadership team, who will contact you with more information. We look forward to meeting you!

Direct contacts:

Registration: Chrissi Wall
MOPPETS program: Beth Gehring
or contact MOPS at mops@lefc.com.

Name:
Address 1:
Address 2:
City:
State:
Zip:
Telephone #
Spouse name
Mom's Birth Date (Month/Day)
Anniversary (00/00/00)
Child's Name
Age as of Sept. 1, 2007
Birthday (00/00/00)
Special instructions/allergies
Child's Name
Age as of Sept. 1, 2007
Birthday (00/00/00)
Special instructions/allergies
Child's Name
Age as of Sept. 1, 2007
Birthday (00/00/00)
Special instructions/allergies
Primary Emergency Contact
Primary Emergency Phone
Secondary Emergency Contact
Secondary Emergency Phone
What church, if any, do you attend?
E-Mail Address:
How did you hear about MOPS?