Name of Child (first, middle, last):

Date of Birth (mm/dd/yy):

Place of Birth (city):

Religion Mother:

Religion Father:

Father's Name (first, middle, last):

Mother's Name (first, middle, maiden):

Parents' Names as they should appear on baptismal certificate:
Certificate will be mailed

Home Address:

City:

State:

ZIP:

Home Phone (555-123-1234):

Cell Phone (555-123-1234):

Work Phone (555-123-1234):

Email address:

Sponsor Name (first, middle, last):

Sponsor Name (first, middle, last):

Requested date of Baptism (mm/dd/yy):

Requested time of Baptism: