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

    Last Name REQUIRED Please fill out this field. Please enter valid data.
  • Middle Name REQUIRED Please fill out this field. Please enter valid data.
  • Date of Birth REQUIRED Please fill out this field. Please enter a date.
  • Place of Birth REQUIRED Please fill out this field. Please enter valid data.
  • State of Birth REQUIRED AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY Please fill out this field.
  • Date of Baptism (Required even if baptized at St. Raphael) REQUIRED Please fill out this field. Please enter a date.
  • Name of Church Where Baptized REQUIRED Please fill out this field. Please enter valid data.
  • Address of Church (unles baptized at St. Raphael) Please enter valid data.
  • City Please enter valid data.

    State None AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY

    Zip Please enter a zip code.
  • Catholic School Attending REQUIRED Please fill out this field. Please enter valid data.
  • Grade in Fall 2021 REQUIRED (Select One) K 1 2 3 4 5 6 7 8 HS Please fill out this field.
  • Mother's First Name REQUIRED Please fill out this field. Please enter valid data.
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  • Mother's Email REQUIRED Please fill out this field. Please enter an email address.
  • Father's First and Last Name REQUIRED Please fill out this field. Please enter valid data.
  • Father's Email REQUIRED Please fill out this field. Please enter an email address.
  • Home Address (where child resides) REQUIRED Please fill out this field. Please enter valid data.
  • City REQUIRED Please fill out this field. Please enter valid data.

    State REQUIRED AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY Please fill out this field.

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