I want to dedicate my child

Your name *

Last name

Email address *

Pastoral Care District *

Select…Blue District - Ps George BrandonGreen District - Ps Jacques RossouwPurple District - Ps Toerien BegemannGold District - Ps Hugo Fourie & Ps Raynier JacobsNot sure

Date you would like to dedicate your child/children on: *

Parent information:

Phone number *

Phone type

MobileHomeWorkOther

Address *

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Gender *

Select…MaleFemale

Marital status *

Select…SingleEngagedMarriedWidow(er)SeparatedDivorcedRemarriedLiving togeher

Spouse Detail:

Spouse Name and Surname

Phone number

Phone type

MobileHomeWorkOther

Child information:

Child's name on Certificate: *

Child's Gender: *

Select…BoyGirl

General:

I hereby commit to phone and talk with my district pastor about the event. *

I hereby give consent that Little Falls Christian Centre may give my contact detail to a leader in order for them to follow up on me. *

Submit

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