Family NEC Resource Boxes: NICU Request Form

Family NEC Resource Boxes: NICU Request Form
Recently Diagnosed Family Resource Box Includes:
- A letter to the family affected by NEC, from the NEC Society
- "10 Things to Know When Your Baby is Diagnosed with NEC" handout
- "What is NEC" handout
- A storybook for the family to read to their precious baby
- Tree of Courage stationery cards
Bereaved Family Resource Box Includes:
- A letter to the family whose baby tragically passed away from NEC, from the NEC Society
- A small blank card, intended for the handwritten message "Holding [baby's name] in our hearts always" to be written by your unit's point person before giving the box to the bereaved family
- "10 Things for Bereaved Parents to Know" handout
- "What is NEC & the NEC Society" handout, for bereaved parents
- A copy of our storybook Forever Our Little One written by the NEC Society's founder & Executive Director
- Wildflower seeds for the family to plant in their baby's honor
- Tree of Courage stationery cards
- Information for bereaved mothers who would like to continue pumping and donate breastmilk
*Spanish available upon request. Email: erinpryor@NECsociety.org

To request boxes for your NICU please carefully fill out the following information:
Your Full Name*

First NameLast Name
Your Email Address*
example@example.com
Please confirm:*

I have received approval for these resource boxes to be given to patient-families affected by NEC in my unit.
Hospital/Institution Name *
Name of point person who will receive and hand out the boxes (we'll address the shipment to this person)*

First NameLast Name
Point Person Email Address *
example@example.com
Shipping Address (where we'll mail the resource boxes)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like resources boxes in Spanish?

Yes
May we add you to the NEC Society's email list?*

YesNo
Thank you for helping us build a world without NEC!
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