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Contact information
We are looking forward to meeting with parents, non profits, community partners and professionals on February 5, 2020. We are asking that you take a moment to complete this form to help us be prepared for the event. Please submit the form by February 3, 2020 at 12PM.
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* Indicates required question
What is your relationship with the pregnancy loss and infant death community? (Check all that apply.)
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Parent
Nonprofit (Please provide the non profit name under other)
Community Partner or Professional (Please provide the business name under other)
Other:
Required
Name
*
Your answer
Email
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Your answer
Address
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Your answer
Phone number
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Your answer
Do we have your permission to print and share your contact information with other attendees at the event?
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Yes
No
Please share the mission, goals, or current projects you would like other attendees to know about you or yourself or your work. (Prefer short, bullet point list to share with attendees.)
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Your answer
What gaps do you see in local services to families preparing for and grieving the loss of a pregnancy or infant in our community?
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Your answer
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