Youth Baptism Registration Form

Grade 5-12 (Ages 10-17)

Your name *

Email address *

Who is filling out this form? *

Parent

Youth

Birthdate *

Gender *

Address *

Grade *

Parent or Guardian Name (s) *

Parent or Guardian Phone Number: *

I have taken the youth baptism course? *

Yes

Not yet.

Please choose the Service you wish for your Baptism *

Who would you like to do the Baptism? *

If choosing Small Group Leader/Other, they must be current members or staff of Heartland.

How would you like to present your testimony? *

Who would you like to do a word of encouragement before your baptism? (1 min long only).

If you know who you want this to be already, put their name below. (Can be the same person or different person who prays) It is your responsibility to contact this person yourself.

Who do you want to have come pray for you before your baptism?

If you know who you want this to be already, put their name below. (Can be the same person or different person who prays) It is your responsibility to contact this person yourself.

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