Application for Keepsake
Please NOTE this is for Kentucky residents ONLY as of right now. Gestational loss must be greater than 14 weeks with birth and burial required.
Applicant Information
Please note - This application is only available to residents of Kentucky at this time. You must have given birth or received a D&E for losses of 14 weeks or greater.
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please note - this is for Kentucky residents ONLY right now. Please confirm you are a KY resident?
*
The loss must have been in the last 12 months. Please confirm your loss was in the last 12 months.
What hospital did your loss occur at?
*
Did you receive one of our care bags during your delivery?
*
Your Baby's Information
Baby's Full Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Loss
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gestation at Birth
*
Birth Weight
*
Birth Length
*
Time of Birth
*
Keepsake Request
Which keepsake are you applying for?
*
Please Select
Keepsake Chest
Personalized Teddy Bear
Personalized Lovey
Do you have any special color requests, etc?
Consent and Permissions
Do you give permission for us to share your story or a portion of it to raise the funds for your gift? Please note, if you say no we will not be able to process your application. We need minimal background details to post for a sponsorship. We do not have to include names, but will need minimal background information. Example - "A mother has applied for personalized bear for a loss that occurred at 14 weeks due to incompetent cervix." It can be as vague as that or as detailed as you wish to provide.
*
Please Select
Yes, with my full name
Yes, anonymously
No
Please include any information that you would like shared about your baby's story online. Please note, you can choose to remain totally anonymous. But, we also want to give you the chance to talk about your baby, if you so choose. This is where you include what you want to be shared for your request online. Be as vague or as detailed as you choose.
*
Any more information you want us to know?
Do you understand that we must raise funds for each item and shipping may take several weeks?
*
Please Select
Yes
No
Do you understand that you are not guaranteed approval by submitting this application? Approval is based on the ability to raise the required funds for all applications.
*
Please Select
Yes
No
Submit
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