Good Samaritan Baby Dedication Form

CHILD’S FULL NAME

FIRST NAME: __________________________________________________________

LAST NAME: __________________________________________________________

CHILD’S BIRTHDATE: __________________

CHILD’S GENDER: ____ MALE ____ FEMALE

NAME OF HOSPITAL: __________________________________________________

CITY ____________________________ STATE ____________(BIRTH LOCATION)

MOTHER’S FULL NAME: _______________________________________________

FATHER’S FULL NAME: _______________________________________________

GODPARENTS: _______________________________________________________

________________________________________________________

CONTACT NAME: ____________________________________________________

CONTACT TELEPHONE NUMBER: _______________________________________

This form is generated and maintained by Good Samaritan Church of God in Christ. For refund and privacy policies, please contact Good Samaritan Church of God in Christ at www.Goodsamaritancogic.org