Waitinglist Application for Tole Friend's Association's Memory Box Program

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 to help to start the process of 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.

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: