Parent/Child Dedication Form

Please complete the form to sign-up your child(ren) for the Parent/Child Dedication Ceremony taking place on Sunday, July 24th at 11:30 am and to confirm your attendance for the Parent/Child Dedication Class. Please note that children must be 4 years old and younger to participate in the ceremony. Please note the deadline to sign up is Sunday, July 17th (by 10:30 am).

PARENT INFORMATION
Parent 1 - Name*
First Last
Parent 1 - Relationship to the Child*
- Mother
- Father
- Guardian
Parent 2 - Name
First Last
Parent 2 - Relationship to the Child
- Mother
- Father
- Guardian
Phone*
Email*
CHILD INFORMATION
Name*
First Last
Date of Birth*
MM slash DD slash YYYY

Child must be 4 years old and under
Gender*
- Male
- Female
Do you have another child that will be dedicated?
- Yes
- No
Child 2 Name*
First Last
Date of Birth*
MM slash DD slash YYYY

Child must be 4 years old and under
Gender*
- Male
- Female
PARENT/CHILD DEDICATION CLASS
Parent/Child Dedication Class Confirmation*
- Check the box to confirm your attendance for the Parent/Child Dedication Class
Parents and Guardians are required to take the Parent/Child Dedication Class to have their baby dedicated and participate in the ceremony. The class will be held on Sunday, July 17th following the 9:00 am service (approximately 10:30 am) and will be approximately 45 minutes.
SUBMIT THE FORM
Statement of Media Consent*
- Check the box to confirm you agree with the statement below.
By submitting this Parent/Child Dedication 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

Parent/Child Dedication Form

PARENT INFORMATION

CHILD INFORMATION

PARENT/CHILD DEDICATION CLASS

SUBMIT THE FORM