Contact Information

Country
Email*
Confirm Email*
Phone*

Tribute Information

Please list the name(s) of the child(ren) you would like to register. Please include last and first names. Middle names are optional. Names registered by October 5 will be included on the back of our T-shirts and in the Program. 

Child's First (Middle Name Optional) - 1*
Child's Last Name - 1*
Born on Earth - 1 (xx/xx/xxxx)*
Born into Heaven - 1 (xx/xx/xxxx)*
Child's First (Middle Name Optional) - 2
Child's Last Name - 2
Born on Earth - 2 (xx/xx/xxxx)
Born into Heaven - 2 (xx/xx/xxxx)
Child's First (Middle Name Optional) - 3
Child's Last Name - 3
Born on Earth - 3 (xx/xx/xxxx)
Born into Heaven - 3 (xx/xx/xxxx)
Additional Names and Dates

Event Information

How did you hear about the event?
  • Facebook
  • Mail Out
  • Newspaper
  • Radio
  • TV
  • Website
  • Word of Mouth
Would you like to be added to our mailing lists?
  • Snail Mail
  • Email
Is this your first time to attend?*
  • Yes
  • No
Please choose a time to attend:*
  • 10 AM (Children with LAST NAMES beginning A-K)
  • 2 PM (Children with LAST NAME beginning L-Z)
How many people will be attending?*

Additional Information

Please send me additional information about:
  • Glory Babies Support Group
  • While We're Waiting Support Group
  • GriefShare Support Group
  • Volunteering
Additional Comments

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