Stained-Glass Butterfly Order Form

Stained-Glass Butterfly Order Form
Caregivers and loved ones can create custom-designed commemorative stained glass butterflies in honor of their children. There are several designs to choose from. Please follow the order form below to make your selections.

For parents/primary caregivers, these butterflies are offered at no-cost.

Please allow several weeks for processing and shipping. You may always contact magriefcenter@bmc.org or call 617-414-7437 for more updates or questions about your order.

A donation in the amount of $50 to the Massachusetts Center for Unexpected Infant & Child Death will support the work of our butterfly garden. For more information on making a donation, please visit https://www.magriefcenter.org/ways-to-give.
Please check here if you are the primary caregiver/parent

Yes, I am the parent/primary caregiverNo, I am not the parent/primary caregiver
Please note - butterflies are available at a cost of $50 each. After you submit this form, you will be contacted by MCUICD for payment.
Please note - up to two butterflies are available to you at no-cost.
Your Name*

First NameLast Name
Email Address*
example@example.com
What is the name of the child you're remembering?*
How many butterflies are included in this order?

12 - Note that butterflies will be identical. If you'd like a second butterfly in a different style, please select '1' and submit this form again with the second design.More than 2 in identical style.
How many?
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.

Design Option Selection
Butterfly designs are completely customizable and offered in three styles. Please see butterfly styles (1/3/7 color options) to choose from.
Our stain glass butterfly are available as three design options. Which color option would you like in your stained-glass butterfly?*

Option 1: 1 ColorOption 2: 3 ColorsOption 3: 7 Colors

Option 1: One Color Design
What color would you like for your stained-glass butterfly?*

Option 2: Three Color Design
What color would like in the #1 spot?*
What color would you like in the #2 spot?*
What color would you like in the #3 spot?*

Option #3: Seven Color Design
What color would you like in the #1 spot?*
What color would you like in the #2 spot?*
What color would you like in the #3 spot?*
What color would you like in the #4 spot?*
What color would you like in the #5 spot?*
What color would you like in the #6 spot?*
What color would you like in the #7 spot?*

Would you like beads spelling the first name, nickname, or initials of the child included on the butterfly?*

YesNo
If yes, how would you like their name presented?*
Which beads would you like to use?

SilverWhite
Would you like to add a heart decal to the end of the name?

YesNo
After you submit this form, you will be contacted by the Massachusetts Center for Unexpected Infant & Child Death to confirm your order and collect applicable payment.
Should be Empty:

Stained-Glass Butterfly Order Form

Design Option Selection

Option 1: One Color Design

Option 2: Three Color Design

Option #3: Seven Color Design