Upper Room - A community loving God and others in the rhythm of Jesus  

Infant Baptism or Dedication

Parent Information

Father's Name: 
Mothers's Name: 
Preferred Phone: 
Email: 
Address 1: 
Address 2: 
City: 
State: 
Zip: 

Child's Information

Child's Name: 
Date of Birth:   Pick a date
Place of Birth (Hospital and City): 

I would like to have my child:

Please indicate which Baptism/Dedication date you prefer (refer back to the web page for upcoming dates)
 Pick a date

Origin of your child's name? (Why did you give your child his/her first and middle names?)

What are a few characteristics that you see in your child at this point in his or her life?

Can you share any stories that would give us more insight into who your child is or what your child is like?

What do you want to baptize or dedicate your child within the Upper Room community?