Name
Phone
Email
Do you want to get baptized?
Yes, I do
No, I do not
How many people want to be baptized?
Just me
2
3
4
5
6
7
8
9
10+
Do you want to invite people along to the baptism/s?
Yes
No
Are you a follower of Jesus?
Yes! I am a Christian
I am a First Time Explorer
I am a New Christian
I've Drifted From Jesus
How old are you?
Under 18
18-20
21-30
31-35
36-40
41-49
50-59
60+
What State Do You Live In?
1. Alabama
2. Alaska
3. Arizona
4. Arkansas
5. California
6. Colorado
7. Connecticut
8. Delaware
9. Florida
10. Georgia
11. Hawaii
12. Idaho
13. Illinois
14. Indiana
15. Iowa
16. Kansas
17. Kentucky
18. Louisiana
19. Maine
20. Maryland
21. Massachusetts
22. Michigan
23. Minnesota
24. Mississippi
25. Missouri
26. Montana
27. Nebraska
28. Nevada
29. New Hampshire
30. New Jersey
31. New Mexico
32. New York
33. North Carolina
34. North Dakota
35. Ohio
36. Oklahoma
37. Oregon
38. Pennsylvania
39. Rhode Island
40. South Carolina
41. South Dakota
42. Tennessee
43. Texas
44. Utah
45. Vermont
46. Virginia
47. Washington
48. West Virginia
49. Wisconsin
50. Wyoming
How many people want to be baptized?
Your Zip Code
Submit