Child Dedication Request

REQUESTOR INFORMATION

NAME OF PERSON REQUESTING DEDICATION

EMAIL OF PERSON REQUESTING DEDICATION

DATE REQUESTED (YYYY-MM-DD)
(Today's Date)


BABY/CHILD INFORMATION

FULL NAME OF BABY/CHILD

DATE OF BIRTH

AGE OF CHILD


PARENT INFORMATION

FATHERS FULL NAME

ADDRES

CITY/PROVINCE

PHONE
Primary (902) 555-5555

Work (902) 555-5555

Cell/Other (902) 555-5555

EMAIL ADDRESS


MOTHERS FULL NAME

ADDRESS

CITY/PROVINCE

PHONE
Primary (902) 555-5555

Work (902) 555-5555

Cell/Other (902) 555-5555

EMAIL ADDRESS


GODPARENT'S INFORMATION

Full Name of Godparent

Full Name of Godparent


MEMBERSHIP AT EPUBC
ARE YOU A MEMBER OF EPUBC?

FATHER

MOTHER

IF NOT, MEMBER OF WHAT CHURCH:

FATHER

MOTHER


Is everything correct?