Section I: Contact information for person requesting a loss kit

Your full name Your name is required.

Relationship to the bereaved family Required. Enter 'self' if requesting kit for yourself.

Your address An address is required.

Your City Please enter your city. Your state -- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Please select a state. Your zip code This is required.Invalid.

Your phone number A phone number is required.Invalid. ex. (555) 555-5555

Your email address Please enter your email address.Please enter a valid email address.

Name of parents

Parent's address

Parent's city Parent's state -- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Parent's zip code

Parent's phone number ex. (555) 555-5555

Parent's email address

Section III: Currently pregnant persons

Is the mother currently pregnant? --- yes no Please select a valid item. *If no, please skip to Section IV

If yes, what is her current gestation? select 4-12 weeks 13-20 weeks 21-25 weeks 26-30 weeks 31-35 weeks 36-39 weeks 40-42 weeks 43+ weeks

What is the adverse perinatal diagnosis?

Is the family planning to terminate or carry the pregnancy?
medically advised termination (the dr advised termination and the family is in agreement)
elective termination (the dr has left the decision up to the family and they have decided to end the pregnancy)
carrying the pregnancy (the family has made an independent decision to stay pregnant as long as possible)

If termination has been chosen, please read our policies section.

Section IV: Baby's Information

Baby's Full Name If the baby was unnamed please type "baby" in the box.

Gender select unknown boy girl Please select.

Date of birth month Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec day unknown 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 2007 2008

Gestation at birth select 4-12 weeks 13-20 weeks 21-25 weeks 26-30 weeks 31-35 weeks 36-39 weeks 40-42 weeks 43+ weeks

Was baby living at time of birth? select yes no currently pregnant Please select a valid item. *If no, skip next two questions.

Date of death month Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec day unknown 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 2007 2008

Baby's age at time of death select 0-6 days 1-3 weeks 4-7 weeks 8-12 weeks 13-16 weeks

Reason for loss (if known):

By checking this box you are acknowledging that this loss occured within the last six (6) months or has yet to occur. If no, please read our policies section and then visit losses past six months.

Section V: What has aleady been provided?

What mementos (if any) did you/the family receive? (check as many that apply)
stuffed animal foot/hand molds pictures necklace or charm journal
baby book birth certificate (legal) birth certificate (memento) hair clipping
foot prints handprints memory box baby gown/clothing hat
booties blanket pamphlets books:
other:

Section VI: Additional Information

How did you hear about A Small Victory? A field is required.

Any additional comments:

Due to high demand and insufficient funds, we are no longer able to provide as many kits as are being requested. Your information will be stored and, as giving increases, your kit will be sent to you. By checking this box you are acknowledging that your kit may take longer than originally expected. Please help us in our fundraising effort.
I understand. This is required.

By clicking submit I am verifying that all information is correct to my knowledge.