IBC PreK Moms Registration 2024/25
Please fill out this form and click submit.
If you are a current group member or have received notification that you have been moved from the waitlist to active membership, you may now register below for the 2024/25 season.
Today's Date
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Name
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Email
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This address will receive a confirmation email
Cell Phone
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Address
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Birth Date
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Husband's Name (if applicable)
Home Church (if applicable)
How did you hear about us?
*
Please provide the name(s), gender, and birth date(s) for each child who will be in our Childcare program during the PreK Moms meetings.
Please list any allergies or special instructions for child(ren) who will be in our Childcare program.
Name & cell number of individual(s) authorized to pick up child(ren) in case of an emergency.
Scholarship
Please select all that apply.
Please contact me with scholarship info.
2024/25 Registration Payment
PreK Moms AM Reg ($30.00)
Requesting Scholarship (0)
Paid by cash or check (0)
PreK Moms AM Reg ($30.00)
Requesting Scholarship (0)
Paid by cash or check (0)
Amount
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
Description
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