Hospital Application
to our Program
(application form will open
in a new window)





Tole Friends
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Hospital Waiting List Registration

If your hospital has not registered with the program and you would like to be included, please register on our waiting list by filling out the form below.

One of the principal requirements to be eligible for the program is an established infant loss Bereavement Program to assist the parents of early infant loss.

Your program needs to have established procedures and follow up for the parents while they are in the hospital and afterwards in order to assist them with grief handling.

The Memory Box Program is only there to help with grief counseling by giving the parents something special to hold what few mementos of the lost child.

These boxes are not for use in other programs or losses. They are made by volunteer artists who do all the work and cover their expenses for supplies and shipping in order to offer support and comfort to parents who normally leave the hospital with heavy hearts and empty arms.

It can take several months until we may be able to add your hospital to our active database, it depends on our volunteers and their ability to cover the expenses of the program.

Please fill out the following information and click 'Submit'.
* = Required Fields

*Name of Hospital:
*Street Address:
Address 2:
*City:
*State:
Other:  
*ZIP/Postal Code:
Country:  
*Email:
*Verify Email:
*Phone:
( )   - Ext.
*Does your Hospital
have an Infant
Bereavement Program:
Yes
No
Please describe
your program:
*Name of
Contact Person:
*Department to
receive Boxes:
*Average need of
Boxes/Month :
0 - 5
6 - 10
11 - 15
16 - 20
more
Comments:
Verify Code:  

 

Hosted by
CDT
(Sponsor of the Memory Box website)
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visit the site
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visit the site

 

 

 
Charity Chair: Brenda Rickman
E-mail
  
 
Tole Friends' Memory Box Program is registered in Utah.
The program does not have any overhead; all work is done by volunteers, donations are used to help our members to defray their cost.
 
 
Webkeeper Anne Strebe