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
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.
Please note - this is for Kentucky residents ONLY right now. Please confirm you are a KY resident?
Your Baby's Information
Baby's Full Name
Date of Birth
-
Month
-
Day
Year
Date
Date of Loss
-
Month
-
Day
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 for fundraising purposes? Please note, we will need minimal background details to post for a sponsorship. We do not have to include names, but will need minimal background information.
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.
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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