ST. JOSEPH CATHOLIC CHURCH 1225 Gallatin Road South Madison, Tennessee 37115 615-865-1071 BAPTISM INFORMATION AND REQUEST FORM INSTRUCTIONS: Fill in or check all the areas that apply. If unsure about any area, leave blank. If completing this form offline (hardcopy), please print information. Date: FAMILY INFORMATION FATHER INFORMATION Father’s Full Name: Main Contact Number: Religion: Baptism Confirmation ( ) - Holy Eucharist Sacraments: check all received. Attended baptism class? If YES, list year: If YES, give parish name, city and state: If YES, what was your role? Yes No Parent Godparent MOTHER INFORMATION Mother’s Full Name: Main Contact Number: Baptism Confirmation Religion: ( ) - Holy Eucharist Sacraments: check all received. Attended baptism class? If YES, list year: If YES, give parish name, city and state: If YES, you attended as a: Yes No Parent Godparent PARENT INFORMATION Home Address: City & State: Zip: Home Phone Number ( ) - If YES, married by Married? If not married, single or divorced? If divorced, who has custody of child(ren)? Give name(s): priest or deacon? Yes No Yes No Single Divorced Registered member(s) of If NO, list parish where registered: City & State: If not registered at any St. Joseph’s parish? parish, check here. Yes No FAMILY INFORMATION Other children in the If YES, have they received sacraments If NO, do you need assistance in preparing the children to receive their sacraments? family? appropriate for their ages? Yes No Yes No If other children, are they If YES, do they go to Catholic If NO, do they attend a Catholic If YES, list the program the child(ren) attend: school age? school? Education Program? Yes No Yes No Yes No CONTINUE ON PAGE 2 Baptism Information and Request Form Page 2 St. Joseph Catholic Church Revised November 27, 2009 FAMILY INFORMATION (Continued) CHILD TO BE BAPTIZED INFORMATION Child’s full name: Date of Birth: City & State of Birth: Saint/religious name for baptism: NOTE: If there is more than two children for baptism, copy this page, enter their name(s) and attach it. GODPARENT INFORMATION GODFATHER INFORMATION (REQUIREMENT FOR GODPARENTS: MUST BE CATHOLIC, AT LEAST 16 YEARS OF AGE AND HAVE RECEIVED ALL SACRAMENTS OF INITIATION) Name: Age Religion: Sacraments of Initiation Year Baptized Year Confirmed Year 1st Communion Registered member(s) If NO, list parish where registered. Attended baptism If YES, list parish where attended and when: Month & of St. Joseph’s parish? class? Year Yes No Yes No GODMOTHER INFORMATION (REQUIREMENT FOR GODPARENTS: MUST BE CATHOLIC, AT LEAST 16 YEARS OF AGE AND HAVE RECEIVED ALL SACRAMENTS OF INITIATION) Name: Age Religion: Sacraments of Initiation Year Baptized Year Confirmed Year 1st Communion Registered member If NO, list parish where registered. Attended baptism If YES, list parish where attended and when: Month & of St. Joseph parish? class? Year Yes No Yes No BAPTISM INFORMATION Date requested Minister requested for baptism Special requests or other considerations: FOR CHURCH USE ONLY Date of Baptism Who attended baptism class? Date Baptism Scheduled Comments Class Father Mother Godfather Godmother Date of Baptism Celebrant Name (PLEASE PRINT) Celebrant Signature IF COMPLETING FORM IN PAPER FORMAT, RETURN IT TO ST. JOSEPH CATHOLIC CHURCH, ATTN: DEACON DON CRAIGHEAD .