Baby's or Child's Full Name *

First Name

Last Name

Mother's Name *

First Name

Last Name

Father's Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Phone *

(###)

###

####

Father's Phone *

(###)

###

####

Membership Status *

We are both members

Only Father is a member

Only Mother is a member

Legal Guardian is a member

I understand that if there are any changes that I must notify Membership Services (434) 534-6904 prior to the date of the Baby Dedication. *

I understand