Galilee MBC - Baby Dedication

Child's First Name(*)

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Child's Middle Name(*)

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Child's Last Name(*)

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Child's DOB(*)

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City of Birth

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State of Birth

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Mother's First Name(*)

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Mother's Middle Name(*)

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Mother's Last Name(*)

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Address(*)

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Address Line 2

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City(*)

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State(*)

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ZIP(*)

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Phone(*)

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Alternate Phone

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Father's First Name

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Father's Middle Name

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Father's Last Name

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Address

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Address Line 2

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City

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State

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ZIP

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Phone

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Alternate Phone

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Maternal Grandmother

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Maternal Grandfather

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Paternal Grandmother

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Paternal Grandfather

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Godmother

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Godfather

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Please select the date you wish to hold your dedication.(*)

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Second choice(*)

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(*)

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Contact Email Address(*)

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