Catholic Diocese of Dallas

Emergency Baptism Form

Hospital Name*
Date of Baptism*	(Format: mm/dd/yyyy)
Name of Baptized Child*
Mothers Maiden Name*
Fathers Name*
Born in City State*
Month, Day, Year*	(Format: mm/dd/yyyy)
According to the Rite of the Roman Catholic Church
Baptized By*
Parents Permanent Address*
Parent Phone No.
Name of Catholic Witnesses
Parents Email Address
As Recorded in the Sick Call Register of this Medical Center