Honor your baby(ies) at the Summit for Perinatal Excellence!

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Honor Your Babies At The Summit for Perinatal Excellence

Parent First Name(s) *

Last Name(s) *

Email *

Phone 1

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country

In Memory Of

Baby's Full Name (please complete a new form for each baby) *

Baby Gender

Loss Type

Date of Delivery/Birth or Stillbirth

Infant Death Date (neonatal/infant death)

Additional Information/Comments:

May we add your baby to our permanent Memorial Wall on our website? (See it here: https://starlegacyfoundation.org/our-stars/) Please indicate yes or no. *

Optional: Submit photos of your baby or of anything that represents your baby to you (an urn, headstone, flower, or anything else meaningful to you). These will only be used on our permanent website memorial wall.

Optional: Submitting a photo(s) indicates permission to use them for the website Our Stars permanent memorial wall.

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Honor your baby(ies) at the Summit for Perinatal Excellence!

Star Legacy Foundation

6400 Flying Cloud Drive, Suite 225

Eden Prairie, MN 55344