Our Lights in Heaven
A Day of Remembrance
Names
Mother's First/Last Name
Father's First/Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Parish
Please Select
St John Vianney
St Justin Martyr
St Gabriel
St Bede
St Mary - Mentor
Other
How many are attending?
1
2
Type of Loss (Please select all that apply):
Miscarriage
Stillbirth
Infant Loss
Child Loss
Name of Child
If there are multiple, list each child's name
When was your loss?
-
Month
-
Day
Year
Date
Do you have any living children?
Yes
No
Is there any information you would like to share with us?
Do you have any questions you would like the panel to discuss/answer?
Allergies/food sensitivities?
Submit
Should be Empty: