Child Baptism Registration Form

Baptism Child Registration Form

Family Name Please enter valid data.

Child's Full Name as it appears on Birth Certificate REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Gender Male Female

City of Birth REQUIRED Please fill out this field. Please enter valid data.

State of Birth REQUIRED Please fill out this field. Please enter valid data.

If born outside the United States, list City and Country Please enter valid data.

Information about the Child's Father

First Name REQUIRED Please fill out this field. Please enter valid data.

Middle Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Is this phone Cell Home Work

Email REQUIRED Please fill out this field. Please enter an email address.

Father's Religion REQUIRED Please fill out this field. Please enter valid data.

Information about the Child's Mother

First Name REQUIRED Please fill out this field. Please enter valid data.

Middle Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Maiden Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Is this phone Cell Home Work

Email REQUIRED Please fill out this field. Please enter an email address.

Mother's Religion REQUIRED Please fill out this field. Please enter valid data.

Family Contact Information

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Primary Family Cell Number REQUIRED Father Mother Please fill out this field.

Primary Family Email Address REQUIRED Father Mother Please fill out this field.

Registered at St. Luke Catholic Church? Yes No

Marital Status Married in the Catholic Church Civil Marriage Single Divorced Widowed

Do you attend Mass regularly? Yes No

Have you attended a Baptism Session within two years? Yes No

Does the birth mother agree with having the child baptized Catholic? REQUIRED Yes No Please fill out this field.

Does the birth father agree with having the child baptized Catholic? REQUIRED Yes No Please fill out this field.

Photo Release Permission

Child Photography Release

Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures. In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.

Child Photo Release REQUIRED Yes No Please fill out this field.

Adult Photo Release

Without compensation, I hereby grant permission to the Catholic Diocese of Saint Augustine to use and reproduce photographs taken of me. These photographs may be used for news and editorial purposes in publications, electronic reproductions (websites and video, including livestream) and/or brochures. In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of Saint Augustine and all of their employees and agents, from all claims and liability relating to said photographs.

Adult Photo Release REQUIRED Yes No Please fill out this field.

In submitting this form, I certify that all information provided on this form, is true and correct; and I hereby give permission for the baptism of the above-named child in the Catholic Church.

Parent's Signatures

Mom's REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

Dad's REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.