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

$ Donation Amount:

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Baby's First and Middle Names

Baby's Last Name

Baby's Birthdate

Baby's Weight

Baby's Gender

Yes No

Second Language Name

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

Tile Type

Would you consider sharing your BC Women’s story? If so, please summarize your story here:

Yes No

Special Placement Location

Your First Name

Your Last Name

Relationship to Baby

Additional Comments

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

City

State / Province

Zip / Postal Code

Phone Number

Payment

Personal Info

Title

First Name *

Last Name

Is this donation on behalf of a company?

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: $600.00

Baby Tile – NICU – Premium

Address+ Phone

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