REQUESTOR INFORMATION

NAME OF PERSON REQUESTING DEDICATION:

EMAIL OF PERSON REQUESTING DEDICATION: 

FULL NAME OF BABY/CHILD:

DATE OF BIRTH:   AGE OF CHILD: 

DATE REQUESTED: 

PARENT INFORMATION

FATHERS FULL NAME: 

ADDRESS: 

CITY/PROVINCE: 

PHONE: HOME WORK CELL (555-5555)

EMAIL ADDRESS: 

GODPARENT'S INFORMATION

Full Name of Godparent: 

Full Name of Godparent: 

MEMBERSHIP AT EPUBC: Are you a member of this Church? FATHER

                                                                                  MOTHER

IF NOT, MEMBER OF WHAT CHURCH: Father:

                                                              Mother:

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