Child's Information
Full Name (for the certificate):
  
Date of Birth:      Gender: M  F
The child lives with? Mother  Father  Both
 

Church Membership
You do not need to be a church member to dedicate your child, however, a requirement for church membership is the completion of our Advance Discipleship Class 101.

If you have not completed the above class, then please check "No" below.
   Mother a member of Solid Rock? Yes  No
   Father a member of Solid Rock? Yes  No
 

Parent Information
Married?  Yes  No  Divorced

Mother's Name:
  
Home Address:


Phone:    E-mail:
Accepted Jesus as your Savior?  Yes  No 

Father's Name:
  
Home Address:
Same as above  

Phone:    E-mail:
Accepted Jesus as your Savior?  Yes  No 
 

Witnesses
Name:
  
      Relationship:   

Name:
  
      Relationship: