Emergency Baptism Form

Also See:

Hospital or Institution Name*
Date of Baptism*
Name of Baptized Child*
Mother's Full Maiden Name*
Father's Name*
Born in City State*
Birthday (Month, Day, Year)*
Please Note: In the case of emergency sacraments performed when in danger of death, the Sacrament of Confirmation can only be supplied by a Catholic Priest/Bishop. Please see Emergency Baptism/ Confirmation Memo for more information.

Was the baptism performed according to the Rite of the Roman Catholic Church?*	Yes No

Was an Emergency Confirmation performed by a Catholic Priest?*	Yes No

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
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