Moms Spring '10 Registration

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Littleton Vineyard Experience Real Life

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Moms & Tots is open to moms in any stage of life with infants, toddlers, preschoolers or elementary-aged children! We are excited to have you join us for Fellowship, Food and Fun!

Simply fill out the form below to register you and your children. If you have multiple children to register in the Tots Program, please enter the first child on the form below and press submit and then you will be prompted to be able to submit additional children.

email address: Leave this field email-address blank:
Homepage: Leave this field homepage blank:
URL: Leave this field url blank:
Comment: Leave this field comment blank:

First Name*:

Last Name*:

Address:

City:

State:

Zip Code:

Phone Number*:

Birthday:

E-mail Address*:

Husband's Name (if applicable):

Do you work outside of the home?:

If yes, how often and doing what?:

Do you regularly attend church?:

If yes, where?:

How did you hear about us?:

I am interested in serving in the following areas:

Fundraising/CommunicationCreative ActivitiesTots ProgramHospitality

Tots Registration

Names of All Children:

Please fill out the information below for EACH child that will be registered in the Tots Program.

Child 1 - First Name:

Child 1 - Date of Birth:

Child 1 - Any Allergies?*:

YesNo

Child 2 - First Name:

Child 2 - Date of Birth:

Child 2 - Any Allergies?:

YesNo

Child 3 - First Name:

Child 3 - Date of Birth:

Child 3 - Any Allergies?:

YesNo

If your child(ren) have allergies, please describe them below and specify which child(ren):

Additional Emergency Contact (Name and Number):

Verification:

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