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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
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
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
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
_____________________________ Patients Name: ______________________ (last name) Birthdate:
https://www.pdf-archive.com/2017/09/25/tfe-patient-information/
25/09/2017 www.pdf-archive.com
Male Female Birthdate: ____________/____________/____________ Age: ______________ Shirt Size:
https://www.pdf-archive.com/2016/11/01/registration-form-waiver/
01/11/2016 www.pdf-archive.com
Birthdate: 9.April.1987 Relation Status:
https://www.pdf-archive.com/2016/02/11/fb-cv/
11/02/2016 www.pdf-archive.com
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
Birthdate ALL CAMPERS:
https://www.pdf-archive.com/2014/02/20/libertydeafcamp-14/
20/02/2014 www.pdf-archive.com
__________________________________________ 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
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
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
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
Birthdate: Age: Marital status: M S W D Occupation:
https://www.pdf-archive.com/2017/01/17/medina-family-chiropractic-acupuncture-new-patient-forms/
16/01/2017 www.pdf-archive.com
Birthdate : 24th March 1970 1.4.
https://www.pdf-archive.com/2016/08/18/scherpereel-arnaud-3/
18/08/2016 www.pdf-archive.com
(birthdate and co-applicant is not ………………………………………………………...………..
https://www.pdf-archive.com/2016/03/08/preferred-customer-info/
08/03/2016 www.pdf-archive.com
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
'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
(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
_____________ Birthdate: _________________ Sex: ____________ Home Address: _______________________________________________________ City:
https://www.pdf-archive.com/2015/08/13/kc-2015-2016-registration-form/
12/08/2015 www.pdf-archive.com