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BABY DEDICATION REQUEST FORM
Child's First Name
Child's Last Name
Child's Date of Birth
Father's First Name
Father's Last Name
Mother's First Name
Mother's Last Name
Address 1
Address 2
Country
City
State
Zip/Postal Code
Email
Phone Number
Mother: Have you received Christ as your personal Savior?
Yes
No
Father: Have you received Christ as your personal Savior?
Yes
No
Are you a member of LOCC
Yes
No
Father's Signature - First
Last
Mother's Signature - First
Last
Submit