Angel Box Request
Please fill out the request form completely. We will send the family an Angel Box once all information is submitted. We try to customize our Angel box in relation to the type of loss, and to have something for all members of the immediate family. Our boxes are intended to be sent out with a delay to avoid the "busy" period immediately after the loss. If you wish to assist with covering the costs of an Angel Box- please refer to Sponsor an Angel Box on our website or check out our Amazon Wish list.
Thank you for your submission for an Angel Box Request and allowing us to Honor another Child gone too soon.
HONOR HOPE HEAL
* Required
Email
*
Your email
Sent from (your name)
*
Your answer
Do you want the box to say it was requested by you?
*
Yes
No, I'd rather stay anonymous
Child's Name
*
Your answer
What is the gender of the child?
Female
Male
Prefer not to say/unknown
Clear selection
Type of Loss
*
Pregnancy/Infant Loss
Sudden Death
Medical Conditions
Other:
Pregnancy/infant loss only. Please include how many weeks gestation if applicable.
Your answer
Medical Conditions only. Please include a brief description on the type of medical condition. Example- Rare Disease, Cancer, Chromosome abnormality.
Your answer
Date of Birth/ Date of loss
Your answer
Name of Family to Send Angel Box to:
*
Your answer
Address the Angel Box should be sent to. (please include city, State, Zipcode)
*
Your answer
Number of additional children in the family. (please include ages if possible)
*
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
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