BECOME A PARTNERING HOSPITAL
To become a Partnering Hospital please complete this form and send to
Angel Fund, P. O. Box 311, New Haven, CT 06502.

Name of Hospital

Contact Person & Title

Address

City/ State/ Zip

Phone

Email

On average we have__________ perinatal losses in Labor and Delivery a year as follows:
..... _____ first trimester_____ second trimester_____third trimester.

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_____ We currently have a Memory Box program and would like to partner with the Angel Fund.

..... Our program is currently funded by __________________________________________.

..... Our boxes include items such as:


..... We provide the following services to families:

..... We would like to partner with the Angel Fund because:

_____ We do not have a memory box program but would like to implement one.

.... We have _______ (#) nurses on our staff certified in perinatal bereavement.

.... We provide the following services to families:

..... We would like to partner with the Angel Fund because:

 

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Angel Fund, Inc.
Post Office Box 311, New Haven, Connecticut 06502
Telephone: (203) 645-7643, Email: cogguillo@sbcglobal.net