Mom to Mom Registration Form

Mom to Mom Registration

*Last Name
*First Name
*Address
*City
*ZIP
*Phone
*Birth Date
Your Church

Add to Brookfield Lutheran’s mailing list?

Yes

Career or volunteer background:

If you are employed outside of your home, how?

CHILDREN being registered for childcare at MOM to MOM (please include their last names if different from your own):

*Child's Name:		*Birthdate:
*Child's Name:		*Birthdate:
*Child's Name:		*Birthdate:

*INFORMATION REQUIRED

Registration is complete when this form and your registration fee (payable to Brookfield Lutheran Church) are received.

MAIL TO: Patty Kilvinger, Brookfield Lutheran Church, 18500 W. Burleigh Rd., Brookfield, WI 53045