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Praying4MyPreemie Order Form (Preemie Poetry)
The birth of a preemie child is an amazing experience, filled with emotions that are often hard for parents to express. Joy, sadness, triumph and fear - the beautiful journey through prematurity should be captured and shared with the world. What better way to do that, than with POETRY!

Kaleena Berryman
Praying4MyPreemie
kaleenaberryman@gmail.com
www.praying4mypreemie.com

Thank you for choosing Praying4MyPreemie to help celebrate your child! With your guidance, we will create a “one of a kind, detailed and just for your child” poem, to celebrate their journey, birthday, a milestone, coming home date – it’s all up to you! You can also honor Mom, Dad, Grandparents, favorite nurse etc., just tell us all we need to know in your answers to the questions below.

Please complete this order form and return it to us as soon as possible. Here is an outline of the process:

1. Complete form and return to Praying4MyPreemie @ kaleenaberryman@gmail.com.
2. Within 24 hours you will receive confirmation of your order form, and payment will be requested.
3. Payment of $25.50 for a tailored poem or $52.00 for an original poem must be made before the writing process begins. Writing a poem takes a great deal of time and thought.
4. After payment is received, an email confirmation will be sent to you. At that time, you will submit five pictures to accompany your poem. That begins the SEVEN business days countdown to complete the work.
5. After a draft is sent, you can make revision requests, free of charge. Our goal 100% satisfaction, and to represent your child in the most accurate way possible.
6. The final poem will be sent to you in three formats, PowerPoint, PDF and JPEG.
7. There are no refunds once work on the poem begins, unless it is not completed.
8. Please be advised that Poetically Yours will maintain the copyright of the poem. However we encourage you to share it and use it to your discretion. We can also provide framing of the poem for an additional cost.
9. Poetically Yours will not share the poem on our blog without your permission.

Poem Sample - Original
Poem Sample - On the Day You Were Born
Poem Sample, Original
Poem Sample, for Dad
PREEMIE POEM ORDER FORM
Answer the Questions below to order your poem! If the poem is to honor Dad, Mom, Nurse or etc., make sure to focus a part of each answer on that person. Feel free to add more important info in the "what else" section. Thank you!
Your Name:
Your answer
Your Child’s Name:
Your answer
Name of Child’s Other Parent:
Your answer
Your Email:
Your answer
Your Relationship to Other Parent:
Your answer
Child’s Birthdate:
MM
/
DD
/
YYYY
Do you want a tailored version of "On the Day You Were Born" or an Original Poem
What Hospital was your child born in?
Your answer
Your City, State:
Your answer
Your Child’s Due date:
MM
/
DD
/
YYYY
How Many Weeks Early Was Your Child and What Was Their Birth Weight?
Your answer
What is Your Child’s Current Age?
Your answer
Tell me about your child’s birth:
Your answer
Tell me about your child’s NICU stay:
Your answer
Are there any fond memories that stand out? Songs you sang? Moments you want included?
Your answer
How is your child doing now?
Your answer
Optional: What do you want the theme of the poem to be? Are we celebrating a milestone like birthday or baby coming home? Is there something about your child’s spirit or your journey that you want to be the heart of the poem?
Your answer
What are your wishes for your child?
Your answer
Is there anything else you want us to know?
Your answer
Does your child have any siblings? Best friends or close cousins you want included?
Your answer
Payment can be made two ways: A. Via Paypal – kaleenaberryman@gmail.com OR B. Via Mail – Kaleena Berryman 110 Warren St. Newark, NJ 07102
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