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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 check all who are members of Galilee.

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

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Second choice(*)

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Contact Email Address(*)
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