The Alana Rose Foundation would love to honor and remember your "angel baby" by including their name and date of death on our virtual Angel Butterfly Display.  Whether you had an early pregnancy loss, stillbirth, or infant loss, your baby's life matters!  In order to respect privacy and the wishes of bereaved parents, we ask that this survey only be completed by the parents/legal guardians of the baby.  By completing this survey, you agree to have your baby's name and date of death on display on our website and future events hosted by the Alana Rose Foundation.  

There is NO COST to include your baby in the Angel Butterfly Ball.  If you are interested in becoming an Angel Butterfly Memorial Sponsor for $50, please visit our website for more information. This allows you to honor your baby with a full-page “In Memory of….” message (with optional photo) displayed on our website.

If you have any questions, please contact AlanaRoseFoundation@gmail.com.  To learn more about the Alana Rose Foundation, please visit AlanaRose.org.

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* 1. Are you a parent/legal guardian who experienced pregnancy or infant loss?

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* 2. What is your first name?

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* 3. What is your last name?

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* 4. Please list your baby's name and date of death exactly as you would like it written on the Angel Butterfly Display.

If you did not name your baby or do not know the exact date of death, please feel free to include whatever wording you feel bests honors your baby (i.e. "Baby Whitmore, 2012", "Baby #3, June 1980", "Angel Baby, 2000", or "Infant Son, July 2019", etc...).

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* 5. What is your email address?

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* 6. Do you want to be added to the email list for the Alana Rose Foundation? 

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* 7. Please share any questions or comments you have below:

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