Baby Dedication Request Form

Child's Full Name *
First Name
Middle
Last Name
Child's Date of Birth*
Father's Name *
First Name
Middle
Last Name
Mother's Name *
First Name
Middle
Last Name
Address *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Email*
Phone Number*
Mother: Have you received Christ as your personal Savior*
Father: Have you received Christ as your personal Savior*
Are you a member of LOCC*
Father's Signature *
First Name
Middle
Last Name
Mother's Signature *
First Name
Middle
Last Name