Patch Registration 

Name of Parent/Guardian
Email
Phone #
Street Address
City
State
Zip
Emergency contact Name and Phone number
Name of Child 1
Allergies of Child 1
Name of Child 2
Allergies of Child 2
Name of Child 3
Allergies of Child 3
Name of Child 4
Allergies of Child 4
Name of Child 5
Allergies of Child 5
Name of Child 6
Allergies of Child 6
Home Church (If applicable)
Submit
By submitting this form, you acknowledge that you understand that although Berean Baptist Church will make every effort to keep your child safe, injuries do happen, and if your child is injured you will be responsible for all medical bills. You further understand that we take pictures at some of our events and use them on social media, our website, and other promotional material and if you wish your child to not be photographed we must have your request in writing.