Star Legacy Foundation Star Legacy Foundation - Dedicated to stillbirth research, education & prevention


Support Referral Form
Today's Date *
Please note: we will make every attempt to reach individuals referred in 48-72 hours. If immediate contact is indicated/requested please call the support line at 952-715-7731, x 1
Referring Individual/Organization Information
Name of referring person *
Organization/Agency Name (If applicable)
Address
Phone
Referring Person's Email *
Infant Information
Baby First Name *
Baby Middle Name
Baby Last Name *
Baby Gender
Date of Delivery/Birth *
Date of Infant Death
Loss Type
Gestational Age at Stillbirth/Birth
For infant death - age in months/days/hours
Race/ethnicity if known
Family Information
Mother's First Name *
Mother's Last Name *
Mother's Maiden Name (If known)
Mother's Phone *
Mother's Email *
Mother's Address *
Parent #2 Full Name *
Parent #2 Phone Number
Number of Other Children in the Family & their ages
Primary language spoken in the home
Additional information
Cause of death, if known
Please describe any immediate needs this family may have at this time *
Is this person aware you are making a referral?
Additional Information

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