Consent for Services

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Who is completing this form?
SGM Volunteer
Nurse / Provider / Healthcare Representative
Funeral Director / Representative
Parent
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I hereby authorize (facility name) ______________________ to give my name and all relevant information to Sufficient Grace Ministries for Women, Inc. so that they can request a loss comfort companion and remembrance photographer to provide memory-making, support, and/or photography services to my family. * This field is required.
Facility Name
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I hereby give Sufficient Grace Ministries consent or any of its legal representatives, and those acting with its authority, permission to:* This field is required.
Memory-Making Keepsakes (Footprints, Handprints, Clay Molds)
Photograph my baby
Photograph me, my family, my baby, or others in varying degrees
Photograph the funeral services
Other (Describe in notes section)
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Additional Instructions
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Large
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Small
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Ok
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Medical Professional / Funeral Home Contact Information* This field is required.
Name
Email
Contact Phone Number
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SGM Comfort Companion/Doula
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Comfort Companion/Doula Email
example@example.com
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SGM Remembrance Photographer
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Remembrance Photographer Email
example@example.com
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SGM Branch* This field is required.
NW Ohio/SE Michigan
NE Ohio
SW Ohio
SE Ohio
Central
Other
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NW Ohio/SE Michigan - Hospital or Other Location* This field is required.
ProMedica Bay Park Hospital
ProMedica Defiance Regional Hospital
ProMedica Flower Hospital
ProMedica Memorial Hospital
Promedica Monroe
ProMedica Toledo Hospital
Mercy Health — St Rita's Medical Center
Mercy Health — St Vincent Medical Center
Community Hospitals & Wellness Centers — Bryan
Fulton County Health Center
Henry County Hospital
Joint Township District Memorial Hospital
Lima Memorial Health System
Parkview Physicians Group
Wilson Health
SGM Office
Client Home
Other
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NE Ohio - Hospital or Other Location* This field is required.
Aultman Hospital
Cleveland Clinic — Hillcrest Hospital
Cleveland Clinic Akron General Akron Health Center
Cleveland Clinic Children's
Cleveland Clinic Fairview Hospital
Cleveland Clinic Main Campus
Rainbow Babies & Children's Hospital
Summa Health System – Akron Campus
Summa Health System – Barberton Campus
SGM Office
Client Home
Other
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Central Ohio - Hospital or Other Location* This field is required.
Mount Carmel - East
Mount Carmel - Grove City
OhioHealth Riverside Methodist Hospital
The Ohio State University Wexner Medical Center
SGM Office
Client Home
Other
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SE Ohio - Hospital or Other Location* This field is required.
Camden Clark Medical Center
Marietta Memorial Hospital
OhioHealth Southeastern Medical Center
SGM Office
Client Home
Other
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SW Ohio - Hospital or Other Location* This field is required.
Kettering Health Main Campus
Mercy Health — Springfield Regional Medical Center
SGM Office
Client Home
Other
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Hospital Department
Labor & Delivery
PICU
NICU
Emergency Department
Other
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Resources Given* This field is required.To be filled out by SGM Volunteer
Dreams of You Bereavement Package over 20 weeks
Dreams of You Miscarriage Package under 20 weeks
Dreams of You Home Birth Miscarriage Kit
Lovey/Tiny Bear
Canvas
Clay Mold
Blanket/Prayer Quilt
Gown/Outfit
Wrap
Sibling Books
Grandparent Books
Seasonal Item/Ornament
Other
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Baptism/Dedication Prayer
Please Select
Please Select
Baptism
Dedication Prayer
Was a Baptism / Dedication Prayer performed?
Please Select
Please Select
Family Member / Friend
Family's Pastor
Hospital Chaplin
SGM Volunteer
Who performed the Baptism / Dedication?
Name of person who performed the Baptism / Dedication.
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Reason for Visit* This field is required.To be filled out by SGM Volunteer
Hospital Visit
Perinatal Hospice Consultation
Perinatal Hospice Hospital Visit
Phone Consultation
Delivering Resources
Follow-Up Support
Other
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Baby Information* This field is required.To be filled out by SGM Volunteer or Medical Professional
Boy
Girl
Gender Unknown
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Baby Gestational Age or Infant Age* This field is required.To be filled out by SGM Volunteer or Medical Professional
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Next section to be filled out by parent. Please give phone or tablet device to parent.
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When SGM provides services:* This field is required.
I would like to be present
I do not need to be present
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Some health insurance companies provide payment for doula services. While Sufficient Grace Ministries offers our services free of charge to families, reimbursement from insurance companies helps us to sustain and cover the necessary costs of our program. We will never bill you or your family for any costs of services. However, we would like permission to bill your insurance if they are willing to cover the cost of our bereavement support and resources.* This field is required.
Yes, I give permission to SGM to bill my insurance for services provided, knowing that it will NOT incur costs to me.
No, I do NOT give permission to SGM to bill my insurance for services provided, knowing that it will NOT incur costs to me.
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In order for SGM to obtain the necessary information to file a claim with your insurance company, your date of birth is required.
Mother's Date of Birth
Year
Month
Day
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I understand that photographs and resources are a free gift from SGM. I, the parent, will receive a link to download edited images (within 8-12 weeks), accompanied by a copyright print release. Parents are responsible for any financial costs incurred in printing images.
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Sufficient Grace Ministries is privileged for the opportunity to be able to take part in such a sacred time for your family and the life of your baby. This consent gives us permission to take photographs.

I hearby give Sufficient Grace Ministries consent or any of its legal representatives, and those acting with its authority, permission to take photographs of me, my family, my baby, and others in varying degrees.
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I give permission for Sufficient Grace Ministries to use the photographs taken for my family as a part in telling the story of the ministry and hereby allowing Sufficient Grace Ministries to use any or all of the photographs for:* This field is required.Please mark atleast one option.
Education & Training
Publications
Presentations
Website
None
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I hereby waive all rights that I may have to any claims for payment or royalties in connection with the use of these photographs and agree that these photographs, including negatives or digital files, shall at all times be the property of Sufficient Grace Ministries.

I hereby release Sufficient Grace Ministries or any of its legal representatives from liability, including any claims of libel or invasion of privacy, directly or indirectly connected with, arising out of or resulting from the taking or authorized use of these photographs.
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Today's Date* This field is required.
Date
Year
Month
Day
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Baby's Name* This field is required.
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Parent's Name (1)* This field is required.
First Name
Last Name
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Parent's Siganture (1)* This field is required.
Clear
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Parent's Name (2)
First Name
Last Name
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Parent's Signature (2)
Clear
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Contact Information
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
-
-
Adams
Allen
Ashland
Ashtabula
Athens
Auglaize
Belmont
Brown
Butler
Carroll
Champaign
Clark
Clermont
Clinton
Columbiana
Coshocton
Crawford
Cuyahoga
Darke
Defiance
Delaware
Erie
Fairfield
Fayette
Franklin
Fulton
Gallia
Geauga
Greene
Guernsey
Hamilton
Hancock
Hardin
Harrison
Henry
Highland
Hocking
Holmes
Huron
Jackson
Jefferson
Knox
Lake
Lawrence
Licking
Logan
Lorain
Lucas
Madison
Mahoning
Marion
Medina
Meigs
Mercer
Miami
Monroe
Montgomery
Morgan
Morrow
Muskingum
Noble
Ottawa
Paulding
Perry
Pickaway
Pike
Portage
Preble
Putnam
Richland
Ross
Sandusky
Scioto
Seneca
Shelby
Stark
Summit
Trumbull
Tuscarawas
Union
Van Wert
Vinton
Warren
Washington
Wayne
Williams
Wood
Wyandot
County
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Primary Phone Number & Email* This field is required.
Please enter your phone
Please enter your email
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Alternate Phone Number & Email
Please enter your phone
Please enter your email
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Demographic Information
Please Select
Please Select
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial/Biracial/Other
Parent 1 - Ethnicity/Race
If Multiracial/Biracial/Other is selected, provide detail
Please Select
Please Select
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial/Biracial/Other
Parent 2 - Ethnicity/Race
If Multiracial/Biracial/Other is selected, provide detail
Please Select
Please Select
Under 18
18-30
31-40
41-50
Over 50
Parent 1 - Age Range
Please Select
Please Select
Under 18
18-30
31-40
41-50
Over 50
Parent 2 - Age Range
Please Select
Please Select
Under $10,000
$10,000-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
Over $100,000
Household Income
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Please read below and give tablet back to SGM Comfort Doula, Remembrance Photographer, or Medical Professional for signature. You will receive an email with a copy of this consent and release form.
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What additional services need to be completed by SGM?
Edit photographs taken by the medical professional or family members
Reach out to the family for funeral home options
Reach out to the family for follow-up support
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CONSENT FOR RELEASE OF PHOTOGRAPHS

Sufficient Grace Ministries is privileged for the opportunity to be able to take part in such a sacred time for your family and the life of your baby. This consent releases the photographs taken by our photographers to those previously mentioned parents above. Please allow 8-12 weeks to receive your professionally-edited images. You will receive edited images via Dropbox link mailed to the emails indicated on your form above.

Sufficient Grace Ministries hereby grants permission and license for personal use and reproduction of photographs to the aforementioned parents.

Copyright of all photographs taken is retained by Sufficient Grace Ministries and its photographers and are not released by this agreement. Reproduction is subject to the following restrictions.

• Commercial Electronic Distribution (use on commercial website or revenue generating blog)
• Entrance into any contest or venue resulting in financial gain
• Sale of prints or materials
• Display of images in any business related or commercial venue
Any photographs released may be used for personal electronic distribution, personal prints, or display of images in personal residence or other non-commercial venue.
Any commercial printer is released from liability regarding the duplication of any of the photographs taken by any photographer affiliated with Sufficient Grace Ministries.

I hereby consent to the release of the photographs taken on behalf of Sufficient Grace Ministries for personal use by the baby's parents.
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Consent for Release Signature* This field is required.SGM Remembrance Photographer or Other Photographer
Clear
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Session NotesOffice Use ONLY
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