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Please only fill this form in if you are the parent of the child. If the plaque is for someone else, please fill in the donate a plaque form.
Child/Childrens Name/s (How you want it on the plaque)
Preferred Contact Method
Flower (Stillborn) $120
Caterpillar (Birth to 1 year) $140
Butterfly (1 year to 12 year) $170
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