Wednesday, February 22, 2012
ASBURY CHURCH
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/ MOMs Group Registration
Asbury Mothers of Munchkins Group Registration Form
Welcome to our MOMs Group! Please complete this form so we can learn some basic information about you.
Name
First
Last
Home Phone
Cell Phone
Email
Address
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Spouse/Significant Other's Name (if applicable)
Date of Anniversary
Do you attend a church?
Yes
No
Where?
Who referred you to MOMs?
Children
Please complete the names and birthdates of your children. If you are currently pregnant, please register "Baby" with your expected due date.
Child 1 Name
First
Last
Child 1 Birthdate
Will Child 1 be coming to MOMs?
Yes
No
Child 2 Name
First
Last
Child 2 Birthdate
Will Child 2 be coming to MOMs?
Yes
No
Child 3 Name
First
Last
Child 3 Birthdate
Will Child 3 be coming to MOMs?
Yes
No
Child 4 Name
First
Last
Child 4 Birthdate
Will Child 4 be coming to MOMs?
Yes
No
I know of a potential candidate for a child care giver
Yes
No
I am interested in participating or have already signed up to serve on the Steering Committee.
Yes
No
Position
I am interested in being a Discussion Group Facilitator
Yes
No
Email
This field is for validation purposes and should be left unchanged.
Contact Us
Asbury Church Administrative Complex
2801 West 15th Street
[View Map]
Wichita, KS 67203
Phone: 316-942-1491
Fax: 316-942-9895
Email us
Sunday Services
Central: 8:00am | 9:15am | 10:45am*
Breakthru: 10:45am
Linwood Ministry Center: 10:45am
West: 10:45am
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