Baby's Name:   

Baby's Date of Birth:   
(mm/dd/yy)   

Date Picture was taken:   
(mm/dd/yy)   

Nominator's relation to child:   

Nominator's Name:   

Address:   

City:   

State/Province:   

Zip Postal Code:   

Daytime Telephone #:   

Evening Telephone #:   

Email Address:   

Upload your picture:   

To attach your file, click BROWSE/CHOOSE FILE above, locate the file on your computer in the pop-up dialog box and click OPEN.