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Bellbrook Community Church
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Child's Name (
Required
)
Date of Birth (
Required
)
Date of Birth
Gender
Male
Female
PARENT INFORMATION
Name of Parent(s) (
Required
)
Address (
Required
)
|
Email (
Required
)
Your Phone Number (
Required
)
Will you be able to email 2-5 photos to PastorWillieCox@outlook.com at least one week prior to dedication service? (
Required
)
Yes
No
In the space below, please list those who will be standing with you at the front AND their relationship to the child being dedicated.
Attendee Information
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