City of residence *

Please include state if not Minnesota

Baby
Boy
Girl

Name of baby

Note: If there is more than one baby, please note the names clearly. Thank you.

Weight

Date of Birth

Hospital (if known)

Please include city

Paternal grandparents

Father's parents Note: If the parents are not married and there are more than one set of parents, pleases mark clearly. Thank you.

City of residence

Maternal grandparents

Mother's parents Note: If the parents are not married and there are more than one set of parents, pleases mark clearly. Thank you.

City of residence

Person submitting information *

Contact number and/or e-mail *

Secret Code

In the box below, enter the Secret Code exactly as it appears above *