Required fields are marked with an asterisk (*).
Name* (full name of person to be baptized)
Date of Birth* (Month/date/year)
Place of Birth* (city/state)
Father’s Name*
Mother’s Name*
Parent’s Home Address*
City*
State* AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip code*
Parents Home Telephone*
Business Telephone Number
Mother
Father
Church Membership*
Godmother’s Name
Godmother’s Address
City
State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip code
Godfather’s Name
Godfather’s Address
Indicate month for Baptism*