Remembrance Worship Night Memorial Information
We will be honoring and remembering the children we have lost (at any age or any stage) through a memorial display at our Remembrance Worship Night on November 9. Please submit as much information as you would like to be included in the display. If you have multiple child losses to submit, please submit one form for each child lost using the same Contact Information Name. Once you submit the form for first child, you may select what fields from the Additional Information section will apply to all submissions. You do not have to fill out remaining boxes more than once.
What to Expect
We will be displaying the information you provide on the screen during the Remembrance Worship Night as a way to honor and remember the child you lost and as a way to find comfort in the fact that others have gone through the loss of a child too. The most recent losses will be the last ones to be displayed.
Your Contact Information
Please include a way we may contact you in case we need to clarify any information with you as we design the memorial.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Memorial Information
Age or Stage of Child at time of loss
Please Select
Miscarriage
Stillbirth
Infant or Shortly After Birth
Child or Adult
Other
Miscarriage Information
Do you have a name for the baby?
yes
no
Full name of baby lost
How would you like the baby name field to be displayed? Suggestions include "Baby Last Name" or nicknames you may have used when talking about the baby during pregnancy.
Approximate gestational age of baby at time of loss (i.e. number of weeks of pregnancy)
Date or Approximate Date of Loss (please include at least the year)
Stillbirth Information
Full name of baby
Age of baby at time of birth (i.e. how many weeks into the pregnancy was the baby born, gestational age)
Date of birth
-
Month
-
Day
Year
Date
Loss of Infant or Shortly After Birth Information
Full name of baby
Baby's birthdate
-
Month
-
Day
Year
Date
What period of time did the baby live after birth?
Please Select
Minutes
Hours
Days
Weeks
Months
Number of minutes the baby lived
Number of hours the baby lived
Number of days the baby lived
Number of weeks the baby lived
Number of months the baby lived
Date of baby's death
-
Month
-
Day
Year
Date
Child or Adult Child Loss
Full name of child
Birthdate
-
Month
-
Day
Year
Date
Age at time of death (years)
Date of death
-
Month
-
Day
Year
Date
Other loss to be remembered
Other loss
Not all child loss circumstances fit into the other options listed. But the loss is still real and the grief is still felt. The general layout of the memorial slides include the fields below. Please use those fields to let us know how to remember with you.
Full name of child
How would you like the name field to be displayed? If you don't have a name, suggestions include "Baby Last Name" or nicknames you may have used when referring to the child.
Date of Birth, Date of Death, age of child at time of loss (approximate or actual)
At minimum, please include the year of your loss. Ages may be gestational ages (i.e. weeks of pregnancy), minutes, days, hours, months, or years. Phrases we will use to describe the other ages include "Carried __ weeks until [date]"; "Born Still on [date]"; "Forever __ [age]. If you have another phrase we can use to describe this circumstance, please include it.
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Additional Information to Include
I am submitting information for multiple losses, please use the information in the fields below for all submissions:
Full names of child's parents
Additional family members
Other information
Not applicable
Full names of child's parent(s)
Note: if the box for multiple submissions is checked, you only need to fill out this box with one submission.
Additional family members who attend Mosaic or who will be attending the worship night may be included if desired. If applicable please include additional family member full name(s) and relationship to child below. (Please note, space is limited)
Note: if the box for multiple submissions is checked, you only need to fill out this box with one submission.
Other information that you would like to be included? Examples: bible verse or quote, special circumstances to share, short eulogy or epitaph information. (Please note, space is limited)
Note: if the box for multiple submissions is checked, you only need to fill out this box with one submission.
Confidential extra information - is there anything else we should know as we design this memorial that will not be published but will help ensure discretion and gentleness for displaying this loss?
The information in this box will be kept confidential and will NOT be displayed publically.
Submit
Should be Empty: