Wufoo
The UVM Children's Hospital Memorial Service
Child or children to be remembered:
Please indicate how to pronounce your child/children's full name(s):
Child or children's date of birth:
Child or children's date of death:
Name(s) of parent(s) or guardian:
Mailing address:
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
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Canada
France
New Zealand
India
Brazil
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Afghanistan
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Wallis & Futuna
Western Sahara
Yemen
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Country
Daytime Phone Number
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Evening Phone Number
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Email address:
Preferred way to contact you:
Email
Daytime Phone
Evening Phone
Are you attending the memorial service?
I plan to attend
I do not plan to attend
Total number of people who will attend:
I do not plan to attend.
Please send me a copy of the program.
Please remove my name from your mailing list.
Photos for slide show
I would like my child /children's photo(s) used in the slide show.
Please email photos to
sarah.cochran@uvmhealth.org
and put your child's name in the subject line. You are welcome to submit up to two photos per child.
Service readings
I would like a reading printed in the service program.
Please upload reading as a Microsoft Word document or PDF. Uploading is strongly preferred, but if you wish to email, please send to
sarah.cochran@uvmhealth.org
.
I would like to help with planning and/or preparation of future services.
If you have any questions, please email
Marlene.Maron@uvmhealth.org
.
Thoughts or comments about previous services:
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