Parents Names *

First Name

Last Name

Phone *

(###)

###

####

Child's Name *

Please list full name as you would like it to appear in the certificate

First Name

Last Name

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Requested Date of Dedication *

Dedications take place during Sunday Service (other than on Communion Sunday)

MM

DD

YYYY

Service *

9:00 AM

11:00 AM

Choose A Pastor To Dedicate Your Child *

Pastor Matt Stewart

Pastor Brad Shedd

Pastor Bill Sparkman

Other