SHACHAH World Ministries of Beltsville, MD

First Name:	Last Name:
Phone:
Email:
Date of Dedication:
Child's Name:	Gender of child:	Male Female

CHURCH INFORMATION:
Are you a member of SHACHAH?	Yes No
Are the parents members of SHACHAH?	Yes No
Are you (the parents) married?	Yes No
Are you (the parents) married to each other?	Yes No
Are you (the parents) a Born Again Christian?	Yes No
God Parents:
Message: