Emersynn Isla Shining Star Foundation: Memorial Star Request
Remember and honor a child gone too soon by dedicating a memorial star. Please complete the form below to send this special tribute of love and light.

*Allow up to 3-4 weeks for delivery
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Recipient's Name *
Recipient's Mailing Address *
Star Name *
Dedication Date (this can be a birthday or date of passing) *
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Indicate if you have a preferred constellation for the memorial star.
*If no preference is given, the star will be placed in the zodiac sign corresponding to the date of dedication *
Was the child a palliative care or hospice patient? *
Please share a brief overview of the child’s medical journey, in whatever way feels most comfortable for you. *
Name the hospital(s) where the child received medical care *
Is this star in memory of your child or a gift to another family? *
If the star is being given as a gift and you would like to include a personalized message, write it below.

Please provide a contact email address in case we have any additional questions.

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How did you hear about us? *
I certify, to the best of my knowledge, all information provided in this application is true and accurate.
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