Tri State Baptism Registration Form
Name

First
Last
Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Phone

### 		-
### 		-
####
Age
Sex
 Male 
 Female 
Email
Date of Salvation

MM 		/
DD 		/
YYYY
Church Name
Youth Pastor Name
Did you receive Jesus as your Lord & Saviour?
 Yes 
 No 
Parent Name

First
Last
Parent's number (17 and under required)

### 		-
### 		-
####
 
     
  Please bring the following items with you on the day of the Baptism:

      1. Towel
      2. Change of clothes
      3. Girls
        • Bathing suit with long t-shirt or cover up
      4. Boys
        • Shorts/ bathing trunks with tank top or t-shirt
      5. Ministers
        • Shorts or bathing suit with light shirt or t-shirt – light colors