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Adult Baptism Registration

First Name*
Last Name*
Address*
City*
State*
ZIP*
Birth Date* (MM/DD/YYYY)
Home Phone
Cell Phone
Email*
* We will be corresponding with you about your meeting and baptism through email.
Please state briefly how and when you accepted Christ as your Savior: *
Why do you want to get baptized? Have you been baptized before (since becoming a Christian)?*
Please Select One:*