First Name

Middle Name

Last Name

Date of Birth

Your Phone Number

Your Address

I would like a

If candidate an adult please select the appropriate answer.

Date Choice #1

Date Choice #2

Date Choice #3

Please provide information for all parties you would like involved in the baptism

How many additional visitors will be attending?

How many of these visitors are children who will need nursery care?

I hereby authorize Connection Church and those acting in pursuit of its authority to record my participation on video, film, photography, and digital recording devices.

I hereby release and discharge Connection Church, its employees and agents, and its lay leadership from all claims and demands arising out of or in connection with the use of such media.

I hereby authorize Connection Church and those acting in pursuit of its authority to exhibit or distribute such recordings, in whole or in part, within Connection Church, on the website, and on local cable access television.