Desired Date of Baptism
-
Month
-
Day
Year
Date
Name of Baptismal Candidate
*
First Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Name of Parent (if candidate is under 18)
First Name
Last Name
Place of Birth
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
T-shirt Selection
*
Emergency Contact
*
Submit
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