Requested Date of Child Dedication (3rd Saturday ONLY) *

MM

DD

YYYY

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Mother's Name *

First Name

Last Name

Mother's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Phone *

Country

(###)

###

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Father's Name *

First Name

Last Name

Father's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Phone *

Country

(###)

###

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