If you are interested in being immersed in accordance with the scripture, please fill out the following form, and place it in a Tzedaka Box at Baruch HaShem.

Name: ____________________________________________________________

Phone No. & Area Code: ______________________________

Are You a Member of BHS? ______________________________

When did you accept Yeshua as your Messiah? (Date) ______________________________

Have you been immersed before? ______________________________

If so, when? ______________________________

Why do you want to be immersed? (Use the space below to answer)

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Do you have any questions or comments? (Use the space below)

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Please Sign: ______________________________

Date: ______________________________

If you are under 18, please have your parent or guardian sign below: ______________________________

I give my permission for ______________________________ to be immersed at the Baruch HaShem Messianic Synagogue mikveh.

Signed: ______________________________

Date: ______________________________