Child's Name:

Street Address:

Apartment Number:

City  State:     Zip:

Age   Birthdate: January February March April May June July August September October November December   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Home Phone:

Work Phone:

Cell Phone:

Parent or Guardian

Email Address:

Home Church:

Special Instructions:

Allergies: (Yes/No)  Make Selection Yes No If yes, Please list:

In according with current Berean Photo Release Statement, I grant permission for my child to be photographed.  Respond yes if you agree Make Selection Yes No