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Braeswood Assembly of God
New Child Dedication Registration
CHILD DEDICATION FORM
page 1 of 1
FATHER'S NAME
required
First Name
Last Name
MOTHER'S NAME
required
First Name
Last Name
MARITAL STATUS
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Select one
Married
Single
Divorced
CHILD'S NAME
required
First Name
Last Name
GENDER
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Select from list
Male
Female
DATE OF BIRTH
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Select one
NAME ON CERTIFICATE
required
First Name
Last Name
ADDRESS
Address
Address Line 2
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Zip Code
PHONE 1
required
Phone Number
PHONE 2
required
Phone Number
EMAIL
required
Email Address
CHILD DEDICATION CEREMONY DATE
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Select all that apply
* required
