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Email *

Child's Name (First, Middle, Last) *

Date of Birth

YYYY

Gender *

Male

Female

Required

Date of Baptism

YYYY

Place of Birth (City & State) *

Mother's Name (First & Last) *

Address (Street, City, Zip Code) *

Mother's Phone Number *

Mother's Email *

Father's Name (First & Last) *

Address

Father's Phone Number *

Father's Email *

Marital Status *

Yes

Do both parents reside in the same home as child? *

Yes

Are you a member of St. John's Lutheran Church *

Yes

I/We are interested in becoming a member

Godparent(s)

A copy of your responses will be emailed to the address you provided.

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