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MOPS at BRCC Registration 100%

      MOPS @ BRCC Registration  7480 West US Hwy 52   •  New Palestine, IN   46163  •  317.861.3880    ________________________________________________________________________________________________________  Last Name          First Name          M.I.    _________________________________________________________________________________________________________  Address    _________________________________________________________________________________________________________ City            State      Zip Code    _________________________________________________________________________________________________________ Home Phone          Cell Phone    _________________________________________________________________________________________________________  Email    Marital Status:  Single    Married    Divorced    Widowed  Husband’s Name (if applicable): _________________________________ Anniversary: __________________  Prior MOPS Member:  No    Yes, at BRCC    Yes, somewhere else  Do you attend church?:  No    Yes, at BRCC    Yes, __________________________________________  How did you find out about MOPS at BRCC? ______________________________________________________  Please list ALL of your children’s names & birthdates: (Please fill out the back for each child who will be in the MOPPETS program.)    _________________________________________________________________________________________________________ Name            Gender      Birthdate    _________________________________________________________________________________________________________ Name            Gender      Birthdate    _________________________________________________________________________________________________________ Name            Gender      Birthdate    _________________________________________________________________________________________________________ Name            Gender      Birthdate    If you are pregnant, when is your due date? ______________________________________________________    Please note, there is a space limitation in MOPS based on volunteer availability in the MOPPETS program.  You  will receive a notice confirming the receipt of your registration.  We will inform you by September 3, 2010 in  regard to your registration status (accepted or on waiting list).  Thank you for understanding.        ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ MOPS Group Only ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐  Date Received: _______________________  Date Registration Fee ($20.00) Received: _______________  Discussion Group Assigned: ________________________________________________________________________              MOPPETS at BRCC Registration    7480 West US Hwy 52   •  New Palestine, IN   46163  •  317.861.3880  Please list only the children who will be in the MOPPETS program.   Child’s Name (Last, First, M.I.): ___________________________________________________________________  Birthdate: __________________________________________________ Gender:  Boy    Girl  Address (if different from mother’s): _____________________________________________________________  Additional Emergency Contact: ___________________________________________________________________  Phone Number: ____________________________________ Relationship: ________________________  Allergies/Important Information: ________________________________________________________________    Child’s Name (Last, First, M.I.): ___________________________________________________________________  Birthdate: __________________________________________________ Gender:  Boy    Girl  Address (if different from mother’s): _____________________________________________________________  Additional Emergency Contact: ___________________________________________________________________  Phone Number: ____________________________________ Relationship: ________________________  Allergies/Important Information: ________________________________________________________________    Child’s Name (Last, First, M.I.): ___________________________________________________________________  Birthdate: __________________________________________________ Gender:  Boy    Girl  Address (if different from mother’s): _____________________________________________________________  Additional Emergency Contact: ___________________________________________________________________  Phone Number: ____________________________________ Relationship: ________________________  Allergies/Important Information: ________________________________________________________________    Child’s Name (Last, First, M.I.): ___________________________________________________________________  Birthdate: __________________________________________________ Gender:  Boy    Girl  Address (if different from mother’s): _____________________________________________________________  Additional Emergency Contact: ___________________________________________________________________  Phone Number: ____________________________________ Relationship: ________________________  Allergies/Important Information: ________________________________________________________________    To register additional children, please attach another MOPPETS registration form.

https://www.pdf-archive.com/2011/07/28/mops-at-brcc-registration/

28/07/2011 www.pdf-archive.com

123pdf 91%

Name must match passport or government issued ID Passenger# 1 Birthdate:

https://www.pdf-archive.com/2014/03/18/123pdf/

18/03/2014 www.pdf-archive.com

VTcommonRentalAppLIHTC 87%

First and last name Social Security number Sex M F Place of birth (city, state) Birthdate (m/d/y) Relationship Head of household First and last name Social Security number Sex M F Place of birth (city, state) Birthdate (m/d/y) Relationship First and last name Social Security number Sex M F Place of birth (city, state) Birthdate (m/d/y) Relationship First and last name Social Security number Sex M F Place of birth (city, state) Birthdate (m/d/y) Relationship First and last name Social Security number Sex M F Place of birth (city, state) Rev.

https://www.pdf-archive.com/2016/04/22/vtcommonrentalapplihtc/

22/04/2016 www.pdf-archive.com

Registration Form 61%

First Name Last Name Cell Phone Email Address Mailing Address First Name Last Name Birthdate Jersey # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Please send registration form &

https://www.pdf-archive.com/2015/09/09/registration-form/

09/09/2015 www.pdf-archive.com

TFE PATIENT INFORMATION 61%

_____________________________ Patients Name: ______________________ (last name) Birthdate:

https://www.pdf-archive.com/2017/09/25/tfe-patient-information/

25/09/2017 www.pdf-archive.com

registration form&waiver 61%

Male Female Birthdate: ____________/____________/____________ Age: ______________ Shirt Size:

https://www.pdf-archive.com/2016/11/01/registration-form-waiver/

01/11/2016 www.pdf-archive.com

fb cv 53%

Birthdate: 9.April.1987 Relation Status:

https://www.pdf-archive.com/2016/02/11/fb-cv/

11/02/2016 www.pdf-archive.com

Rules - 2017 IVP World Cup Qualifier by FIGO7 52%

TOURNAMENT RULES:

https://www.pdf-archive.com/2017/07/10/rules-2017-ivp-world-cup-qualifier-by-figo7/

10/07/2017 www.pdf-archive.com

LibertyDeafCamp 14 52%

Birthdate ALL CAMPERS:

https://www.pdf-archive.com/2014/02/20/libertydeafcamp-14/

20/02/2014 www.pdf-archive.com

17 09 LO App Form 52%

__________________________________________ Birthdate: _____________________ Email: ______________________________________________ Occupation: ____________________ State in which you reside:

https://www.pdf-archive.com/2017/09/25/17-09-lo-app-form/

25/09/2017 www.pdf-archive.com

Yaayah registration 51%

First Name ______________________________________ Last Name ____________________________________ Male Grade Completed by Beginning of Camp ____________ Female Birthdate M_____D_____Y_____ Address _____________________________________ City _____________________ State ______ Parent/Guardian’s Name ___________________________ Zip _________ Email ________________________________________ Parent/Guardian’s Address (if different than camper) ______________________________________________________ City ____________________________ State _______ Zip _________ Relationship _____________________ Telephone (day) _________________________ (evening) ________________________ (cell) _____________________ Emergency Contact _____________________________ Relationship _____________________ Phone _____________ What church do you attend?

https://www.pdf-archive.com/2016/05/25/yaayah-registration/

25/05/2016 www.pdf-archive.com

Student-Registration-Form 50%

Name of official document (specify) Student’s Legal Name Student’s AKA Name (name by which the student is commonly known in the family and community) Surname AKA Surname First Name AKA First Name Birthdate YYYY MM DD Middle Name Gender Female Male Other / Prefer not to disclose Address City Phone Number Unlisted Postal Code Quadrant of City (please select one) NW Listed NE SW Residential District SE MEDICAL INFORMATION (Note:

https://www.pdf-archive.com/2018/05/01/student-registration-form/

01/05/2018 www.pdf-archive.com

Medina Family Chiropractic & Acupuncture New Patient Forms 50%

Birthdate: Age: Marital status: M S W D Occupation:

https://www.pdf-archive.com/2017/01/17/medina-family-chiropractic-acupuncture-new-patient-forms/

17/01/2017 www.pdf-archive.com

Final Paper 50%

name Taylor Ashley Kevin Elizabeth birthdate 11/10/1989 3/6/1976 6/26/1962 6/11/1966 sex Male Female Male Female zipcode 60067 60185 19125 13090 smoker?

https://www.pdf-archive.com/2019/05/25/final-paper/

25/05/2019 www.pdf-archive.com

Scherpereel Arnaud (3) 50%

Birthdate : 24th March 1970 1.4.

https://www.pdf-archive.com/2016/08/18/scherpereel-arnaud-3/

18/08/2016 www.pdf-archive.com

Preferred Customer Info 47%

(birthdate and co-applicant is not ………………………………………………………...………..

https://www.pdf-archive.com/2016/03/08/preferred-customer-info/

08/03/2016 www.pdf-archive.com

Shakespeare Religion in Hamlet wiki pdf 45%

His birthdate remains unknown, but it is assumed he was born on 23 April 1564, and that is when it is celebrated worldwide.

https://www.pdf-archive.com/2015/01/28/shakespeare-religion-in-hamlet-wiki-pdf/

28/01/2015 www.pdf-archive.com

Relational Databases L2 notes 44%

'gorilla') birthdate — the animal's date of birth (example:

https://www.pdf-archive.com/2016/07/14/relational-databases-l2-notes/

14/07/2016 www.pdf-archive.com

2018 39%

(Jeremiah 29:10) Babylon falls to Persia October 539 BCE, (Encyclopœdia Britannica, 1946, Vol.2, p.852) Cyrus ordered the Jews to return to their homeland later that year, so by 538 BCE the desolation of Jerusalem is no longer in place, countingback 70 from 538 bce would bring us to 608 bce, from 608 bce if we begin to count the 2625 years then the first year of our count would point to 607 bce (like when your birthdate is year 2000, you become 1 year old at year 2001) and the 2625th to 2018 ce 1290+1335=2625-607bce=2018 Blessed is he who waits and ARRIVES at the 1,335 days namely Jesus Christ ------------------------------------------------------------------------------------------------------------------------------"None of the wicked shall understand;

https://www.pdf-archive.com/2018/02/19/2018/

19/02/2018 www.pdf-archive.com