Baptism Registration

• • Last Name *
    
    
• • Father's Name *
    
    
• • Mother's Name *
    
    
• • Street Address *
    
    
• • City & Zip Code: *
    
    
• • Telephone Number
    
    
• • Cell phone Number *Optional:
    
    
• • Email
    
    
• • Child/Adult Full Name Being Baptized: *
    
    
• • Date of Birth (Month/Date/Year) *
    
    
• • Place of Birth *
    
    
• • Have Parents been Baptized? Yes/No *If Yes, Where *
    
    
• • Have Parents made Profession of Faith? Yes/No. *If Yes, Where (At least one must have) *
    
    
• • Please List any Brothers or Sisters and include the Birth Date of each. *
    
    
• • First Preferred Date and Service Time:(*Please reference calendar) *
    
    
• • Second Preferred Date and Service Time: *
    
    
• • Which month will you come to meet the Elders . (Elders meet the second Tuesday of each month at 6:30 pm) *
    
    
• • Would you like to have a relative or friend who has been or currently is an Elder or Pastor assist in the Baptism? Yes/No * If yes, please list name and title.(ex. Elder/Pastor) *
    
    

Authentication Text*
(Enter the text in the image above into this field.)

NOTE: Do Not Alter These Fields: