Please complete ONE FORM for EACH PERSON attending

Before registering online, please read the Registration Packet

for complete information on the Gathering Weekend.

Save & Return (Optional)

Don't think you will have time to fill this whole thing out in one setting? Sign in now, fill out as much as you can and hit save progress below and complete this form later.

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone (add dashes) *

Email Address *

Child or Sibling

This is My...

Birth Date

Death Date

Child or Sibling

This is My...

Birth Date

Death Date

Child or Sibling

This is My...

Birth Date

Death Date

Child or Sibling

This is My...

Birth Date

Death Date

Are you: (check any or all that apply)

Newly Bereaved (less than 3 years)

No Other Surviving Children

Bereaved Sibling

First Time Gathering Attendee

Not A Bereaved Parent, Sibling, or Grandparent

Registration Fee *

Early Bird Registration (Until June 1st $75

Regular Registration Adult (After June 1st $95)

BPUSA Chapter Leader or Workshop Presenter (Until June 1st $50)

BPUSA Chapter Leader or Workshop Presenter (After June 1st $75)

Student or Active Military W/ID ($50)

Thursday Meet & Greet

Thursday Meet & Greet ($25)

Meal Plan

Friday & Saturday: 2 breakfasts, 2 lunches, 2 dinners - Sunday: 1 breakfast ($220)

Individual Meals (if not choosing a Meal Plan)

Special Diet Needs and/or Food Allergies (explain in detail)

Picture Buttons

# of Picture Buttons $5 each (slide presentation photo will be used for picture button)

Sponsorship Opportunities

Gathering Program Memorial Page

Gathering Program Memorial Page 1/4 page ($25)

Gathering Program Memorial Page 1/2 page ($50)

Gathering Program Memorial Page full page ($100)

Gathering Program Business Ad

$25 Business Card

$75 Quarter Page

$150 Half Page

$300 Full Page

Donation to BPUSA in memory of my child, sibling, grandchild.

In memory of:

I'm willing to volunteer during the Gathering

Meal Ticket Collector

Workshop Monitor

Raffle Table Monitor

Other or As Needed

Current Total:

$0.00

Payment Method *

Credit Card

Pay Pal

Check

Memorial Slide Presentation Form

The slideshow presentation during the Candlelight Service is a meaningful part of our Gatherings.

If you are attending the 2022 Gathering, please upload a photo of your child, sibling, or grandchild (alone in picture) on this form.

Not A Bereaved Parent, Sibling, or Grandparent

I am opting out of the Memorial slide presentation for the Candle Lighting Ceremony

#1 Child/Sibling/Grandchild's Name: *

Phonetic Pronunciation: *

Birth Date: *

Date of Death: *

Slideshow Presentation Photo: *

The picture should be on file from a past National BPUSA Gathering Conference.

Include my child's NAME ONLY with appropriate representation (no photo available).

I am uploading my child's picture

I am emailing my picture Deadline July 9th

I am mailing my picture Deadline July 1st

Upload Picture of Child, Sibling, Grandchild Here (File name will appear under the browse button.)

I have another child/grandchild/sibling.

#2 Child/Sibling/Grandchild's Name: *

Phonetic Pronunciation: *

Birth Date: *

Date of Death: *

Slideshow Presentation Photo:

The picture should be on file from a past gathering.

Include my child's NAME ONLY with appropriate representation (no photo available).

I am uploading my child's picture

I am mailing/emailing my picture

Upload Picture of Child, Sibling, Grandchild Here (File name will appear under the browse button.)

#3 Child/Sibling/Grandchild's Name:

Phonetic Pronunciation:

Birth Date:

Date of Death:

Slideshow Presentation Photo:

The picture should be on file from a past gathering.

Include my child's NAME ONLY with appropriate representation (no photo available).

I am uploading my child's picture

I am mailing/emailing my picture

Upload Picture of Child, Sibling, Grandchild Here (File name will appear under the browse button.)

#4 Child/Sibling/Grandchild's Name:

Phonetic Pronunciation:

Birth Date:

Date of Death:

Slideshow Presentation Photo:

The picture should be on file from a past gathering.

Include my child's NAME ONLY with appropriate representation (no photo available).

I am uploading my child's picture

I am mailing/emailing my picture

Upload Picture of Child, Sibling, Grandchild Here (File name will appear under the browse button.)

#5 Child/Sibling/Grandchild's Name:

Phonetic Pronunciation:

Birth Date:

Date of Death:

Slideshow Presentation Photo:

The picture should be on file from a past gathering.

Include my child's NAME ONLY with appropriate representation (no photo available).

I am uploading my child's picture

I am mailing/emailing my picture

Upload Picture of Child Here (File name will appear under the browse button.)

If you choose to email or mail your photo(s), your picture and a completed form (form the Registration Packet) are needed for each child being remembered. The picture submitted must be of the child/sibling/grandchild only. Email your photo to bpusaweblinks@gmail.com no later than July 9th. You will receive a confirmation email back. If you don't, please follow up. You don't want to miss out seeing your child's picture included in the slide presentation.

If you're mailing the photo, send photo and form to Matthew Groves, 1190 Worthington Drive,
Bridgeport, WV 26330, no later than July 1st. Please put child’s name and address on the back of the
photo. You can pick up your photo(s) at the Gathering Registration Table when you arrive or enclose a
postage paid addressed envelope so that your photo(s) can be immediately returned to you.

When you click "Check Out", it will take you to Paypal,

where you can pay through Paypal or with a credit card.