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Baptism Sign-Up Form

Please complete the form to sign-up you or your child (ages 5 - 17) for our upcoming Baptism Service on Sunday, July 3rd at 11:30 am and to confirm your attendance for our Baptism Class on Sunday, July 3rd following the 9 am service (approximately 10:30 am).

BAPTISM CANDIDATE INFORMATION
Name of Person Being Baptized*
First Last
Date of Birth*
MM slash DD slash YYYY

Baptism candidates must be 5 years old and up.
Gender*
- Male
- Female
Is the person being baptized a youth (ages 5 to 17)?*
- Yes
- No
Phone*
Email*
Do you have any physical or health condition(s) that require special accommodations in order for you to participate in the Baptism?*
- Yes
- No
If yes, please explain so our staff can prepare accordingly.
PARENT INFORMATION
Parent/Guardian Name*
First Last
Relationship to Child*
- Mother
- Father
- Guardian
Parent/Guardian Phone*
Parent/Guardian Email*
Does your child have any physical or health condition(s) that require special accommodations in order for them to participate in the Baptism?*
- Yes
- No
If yes, please explain so our staff can prepare accordingly.
Statement of Parental/Guardian Consent*
- Check the box to confirm your consent for your child to be baptized.
BAPTISM CLASS
Baptism Class Confirmation*
- Check the box to confirm your attendance for Baptism Class on Sunday, July 3rd following the 9 am service (approximately 10:30 am - 11:15 am).
Baptism Class is held to help prepare our baptism candidates for their Baptism and provide important information about their next steps in Christ. Parents of youth candidates (ages 5 to 17) must attend the class with their child.
SUBMIT THE FORM
Statement of Media Consent*
- Check the box to confirm you agree with the statement below.
By submitting this Baptism Form, you acknowledge release of any photographs and video that may be taken of you, your child or your family during this event by Harvest Life Church or Lyle and Deborah Dukes Ministries to be used for our purpose.
Enter the characters as shown in the image.

CONTACT INFORMATION

Address:
14401 Telegraph Road
Woodbridge, VA 22192

Phone:
703-490-4040

Fax:
703-497-7321

Email:
info@harvestlifechangers.com

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