GLA Lagos (HQ) - BABY DEDICATION FORM

CHILD DEDICATION REQUEST

RELATIONSHIP TO CHILD

Father

Mother

Other

Marital Status

Single

Divorced

Separated

Widowed

If "other", please indicate your relationship with child

First Name

Last Name

Email

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

First Name

Last Name

Email

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

First Name

Last Name

Email

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Child's First Name

Other Given Names as you would like them to be recorded on dedication certificate

Date of Birth

Child's Gender

Male

Female

Proposed Date of Dedication

Do You Have Any special requests for the ceremony?

No

Yes

Please indicate nature of requirements

Anything else you would like to share?