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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: