Berkley Community Church

Please register each child individually. All information is kept confidential.

Childs Name: *
Nickname:
Address: *
City: *
Zip: *
Phone Number: *
Cell Phone: *
Birthday: *
Fathers Name: *
Mothers Name: *
Email: *
Emergency Contact Name (other than parent): *
Phone Number: *
Special Instructions or Allergies:

2855 Wiltshire, Berkley, MI [driving directions]