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CHILD-DEDICATION REGISTRATION
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1
Name
*
This field is required.
First Name
Last Name
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2
Please Submit Your Baby's First & Last Name
(please make sure the spelling is correct)
*
This field is required.
First Name
Last Name
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3
Please Upload a High Quality & Clear Image of Your Baby
(or email one to info@kpbc.net with the name of your child in the subject line)
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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4
Name of Father
*
This field is required.
First Name
Last Name
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5
Name of Mother
*
This field is required.
First Name
Last Name
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6
Parents are Followers of Jesus Christ and are Active Members of KPBC:
*
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YES
NO
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7
Both Parents are Legally Married to Each Other:
*
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YES
NO
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8
My child is under three years of age:
*
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YES
NO
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9
Will both parents be present for the dedication?
*
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YES
NO
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10
Is there anything specific we can be praying with you for your child?
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11
Email
*
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example@example.com
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12
Cell Number
*
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Area Code
Phone Number
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