Baby Tile – NICU – Deluxe – BC Women's Health Foundation

$ Donation Amount:

‎

Baby's First and Middle Names *

Baby's Last Name *

Baby's Birthdate

Baby's Weight

Baby's Gender

Second Language Name Request (+ $35 extra) Yes No

Second Language Name

Second Language Name Optional Upload (image or PDF files only)

Select File(s)

Tile Type *

Additional Names Yes No

Additional Baby Name

Additional Baby Weight

Additional Baby Birthdate

Additional Baby Tile Type

Additional Baby Name

Additional Baby Weight

Additional Baby Birthdate

Additional Baby Tile Type

Tile Message – up to 20 words (available for Deluxe tiles only when “Additional Names” has not been selected)

Special Placement (+ $50 extra) Yes No

Special Placement Location

Your First Name

Your Last Name

Relationship to Baby

Additional Comments

Parent Information - Same as above?

Parents' Name(s)

Parent's Country

Parent's Address

Parent's Unit (if applicable)

Parent's City

Parent's State/Province

Parent's Zip / Postal Code

Parent's Phone Number

Parent's Email

Address + Phone

Country *

Address 1 *

Address 2

City *

State / Province *

Zip / Postal Code *

Phone Number *

Payment

Personal Info

Title

First Name *

Last Name

Company Name

Email Address *

Make this an anonymous donation.

Comment

Credit Card Info

This is a secure SSL encrypted payment.

Card Number *

CVC *

Cardholder Name *

Expiration *

Billing Details

Country *

Address 1 *

Address 2

City *

Province *

Zip / Postal Code *

Donation Total: $1,200.00

Baby Tile – NICU – Deluxe

Address + Phone

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Normalizing Recurrent Pregnancy Loss

“What Gets Measured Gets Done”

“Women’s Health Needs To Be Front and Centre”