Remembrance

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First Name*

Last name*

Email*

Phone

Please tick one of the following:

I am/We are bereaved parent(s)

I am a family member/friend of bereaved parent(s)

Other (please provide details in the message box below)

Type your message here*

Optional: Please choose one or more of the following:

Please add me to your email list

I would like a remembrance card on the anniversary (please complete details below)

I would like our baby's/babies' name(s) to be added to the Remembrance Page (please complete details below)

Name(s) of parent(s) - first & last names

Name of baby/babies (full name including last name)

Please add the remembrance date you wish to commemorate (dd/mm/yyyyy)

Address (full address inc. post code

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