"Chipi Box" Request Form

"Chipi Box" Request Form

Helping you by sending a little light during one of life’s darkest moments.
Your Name

First NameLast Name
Name of the person/people you are requesting the box for (if it is not for yourself)

First NameLast Name
Address (Note: Must be in Lambton County, Ontario. However sometimes special considerations can be made depending on your location.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
IG Handle:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
You are welcome to share any other siblings or other losses here:
What is your baby's name (if you named them) or what symbol or sign makes you think of them?
If you would like to share, what is your baby's death/birthday?
If you'd like, you're welcome to share your story here. This is a safe and caring space to honor your experience -whether it's how old they were, a memory you cherish, a moment of deep heartbreak, or something beautiful that has emerged along the way.
As part of this service, each baby is lovingly honored by having their name included on a remembrance flag and a list of babies remembered through Chipi Boxes. Is it okay to include your baby's name? If you'd like to be tagged when we share, you can include your Instagram handle below - or feel free to leave it blank if you'd prefer to remain anonymous.
Thank you for trusting us with your story and for allowing us to honor your baby in this way. We hope this small gesture brings even a little comfort to your heart or to the heart of someone you care about. You are not alone, and your love and loss are seen and remembered.

With Love,

Carmen
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