Baby Dedication Request - Good Samaritan Haitian Alliance Church

CHILDS INFORMATION

*Childs Full Name

*Gender

Male

Female

*Date of Birth

*Hospital where child was born

*First Option

*Second Option

PARENTS INFORMATION

*Mothers Name

*Fathers Name

*Address(Please include City, State and Zip)

*Email

*Home Phone

*Mothers Work

*Fathers Work

*Are one or both parents born again Christians

Yes

Still Considering

Unsure

*Are one or both parents members of Good Samaritan Haitian Alliance Church

Yes

*Marital Status

Other (please explain)

GODPARENTS INFORMATION

*Godmothers Name

*Godfathers Name

*Who will participate in the Baby Dedication Ceremony?

*Please attach a copy of the Confirmation of Birthformat in .pdf, .png, .jpg, .doc or .docx