Initial Startup Contract Cailins Memories… A commemorative service honoring all babies lives, Inc. 47 Stonegate Road Greenville, NY 12083 (518) 253-3470 Dear Nurse Manager: For the year of 2007 and beyond we have written new order forms in order to keep track of our inventory and to serve you in a more timely fashion. We also use all paperwork provided as part of our organizational grant-writing process. This will serve all our hospitals and offices better. Below you will find the initial start contract you will fill out and return to participate in our perinatal bereavement program. We offer to your hospital the following donations, free of charge: 1. Cailin’s Memory Box Program 2. Cailin’s Early Pregnancy Loss Packet/Miscarriage Packet 3. Educational inservices for your staff on perinatal bereavement. We will be available to deliver both Memory Programs in conjunction with a scheduled inservice. If the educational component is not desired both Memory Programs may be scheduled for pickup at our organizational headquarters in Westerlo NY. For initial startup of our program/or for our current hospitals and offices we ask that the most senior nurse manager of said unit approve having our program on their unit and within their hospital/office. Please check off if you are interested in our educational component and if a fundraising opportunity is available at your facility. After the initial approval process please name your designated liaison person, so we will know who to contact in the future. On signing this I ___________________________, Nurse Manager of _______________ am requesting Cailin’s Memories….a commemorative service honoring all babies lives, Inc. to provide a memory box and miscarriage packet program to our facility. We name ____________________________ to speak on behalf of our unit/office. ? We request Cailin’s Memories….a commemorative service honoring all babies’ lives, Inc. to provide inservices to our staff members. ? We approve Cailin’s Memories….a commemorative service honoring all babies’ lives, Inc. to fundraise at our facility to defray to cost of the program. ________________________________________________________________ Signature of Nurse Manager Date Signature of Liaison Contact and phone number/e-mail Date Lesley Gorny and Jean Rowe Date Founders of Cailin’s Memories…a commemorative service honoring all babies lives, Inc. Sincerely, Lesley Gorny-Hornbeck and Jean Rowe Cailin’s Memories…. a commemorative service honoring all babies lives, Inc. Initial Startup Contract Cailins Memories… A commemorative service honoring all babies lives, Inc. 47 Stonegate Road Greenville, NY 12083 (518) 253-3470 Dear Nurse Manager: For the year of 2007 and beyond we have written new order forms in order to keep track of our inventory and to serve you in a more timely fashion. We also use all paperwork provided as part of our organizational grant-writing process. This will serve all our hospitals and offices better. Below you will find the initial start contract you will fill out and return to participate in our perinatal bereavement program. We offer to your hospital the following donations, free of charge: 1. Cailin’s Memory Box Program 2. Cailin’s Early Pregnancy Loss Packet/Miscarriage Packet 3. Educational inservices for your staff on perinatal bereavement. We will be available to deliver both Memory Programs in conjunction with a scheduled inservice. If the educational component is not desired both Memory Programs may be scheduled for pickup at our organizational headquarters in Westerlo NY. For initial startup of our program/or for our current hospitals and offices we ask that the most senior nurse manager of said unit approve having our program on their unit and within their hospital/office. Please check off if you are interested in our educational component and if a fundraising opportunity is available at your facility. After the initial approval process please name your designated liaison person, so we will know who to contact in the future. On signing this I ___________________________, Nurse Manager of _______________ am requesting Cailin’s Memories….a commemorative service honoring all babies lives, Inc. to provide a memory box and miscarriage packet program to our facility. We name ____________________________ to speak on behalf of our unit/office. ? We request Cailin’s Memories….a commemorative service honoring all babies’ lives, Inc. to provide inservices to our staff members. ? We approve Cailin’s Memories….a commemorative service honoring all babies’ lives, Inc. to fundraise at our facility to defray to cost of the program. ________________________________________________________________ Signature of Nurse Manager Date Signature of Liaison Contact and phone number/e-mail Date Lesley Gorny and Jean Rowe Date Founders of Cailin’s Memories…a commemorative service honoring all babies lives, Inc. Sincerely, Lesley Gorny-Hornbeck and Jean Rowe Cailin’s Memories…. a commemorative service honoring all babies lives, Inc. Order Form for Perinatal Bereavement Supplies Order Form for Supplies Cailin’s Memory Boxes are for babies who are able to have physical memories created. The first items in the box are ‘baby items’. When available we provide beautiful hand made outfit set with matching blanket; both are size appropriate and are made from soft baby materials and yarn. We offer a keepsake outfit to parents-this is an exact duplicate outfit for the parents to keep if they wish for the baby to remain in the original outfit. We will also provide an angel bear which may appear in pictures with him/her-simply because every baby needs a teddy bear. Next we have created a matching bracelet combo for mom and baby; this set symbolizes the unbreakable bond between mother and child. The second items are ‘memory items’. Inside a hand made cloth holder you will find four ‘print cards’ for baby’s feet, hand, and possibly ear prints. Matching this is a sympathy card for caregivers to sign; inside this card is a packet of Forget-me-not seeds for the parents to plant in remembrance of their precious baby. A Certificate of Life is included; this commemorative birth certificate is especially important to babies who are born still since they are not issued anything other than a death certificate in most states currently--New York state included. Cailin’s Early Pregnancy Loss Packet/Miscarriage Packet are for smaller babies for whom making physical memories is not possible; first trimester pregnancy losses. Inside of our hand made cloth holder you will find a Certificate of Life , a matching sympathy card for caretakers to sign is also included and will contain a seed packet of Forget-me-nots for parents to plant in remembrance of their baby and an angel bear to hug and hold onto. A journal with matching bookmark is a therapeutic tool for your patients to write down thoughts and aids in starting to process their feelings. A special packets of poems written by bereaved parents is also inside; these special writings may help your patient to express their feelings about their loss. A remembrance candle for your patients to light on special days they wish to honor their little one. A pregnancy and infant loss support ribbon/PAILS ribbon is intended for anyone to wear who wishes to remember a lost baby and help raise awareness. Also, our brochure, card, and a little instruction packets are inside to help explain all our memory items. To cut down on the cost of repeat items when hospitals are working with more than one Non-Profit organization we will supplement the supplies needed for their bereavement program. Please let us know what items you already have. This with enable us to provide to hospitals and families who have nothing. Memory Boxes per Month
