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First Name

Last Name

Phone Number

Email

Address

Birth date / Age

Shirt Size (For Water Baptism tee-shirt)

Have you accepted Jesus as your Lord and Saviour?

YesNo

Have you ever been baptized in any other way; sprinkling, christening or blessings?

YesNo

Have you ever been baptized in Water by immersion?

YesNo

How long have you been born again?

How did you begin your relationship with Christ? Please describe the process

How has your life changed now that you've begun this relationship with Christ?

Write 3 words/ phrases that describes your walk with Jesus

Why have you decided to be water baptised?

Are you Available for a 3-Part Baptism Course with a minimum of 6 hours to review the scripture on the basis and significance of Water Baptism?

YesNoNot Sure