Contact Us • NICU Helping Hands

Name *

Email *

Phone *

I am... *A parent/family memberAffiliated with a hospitalAn adult and I would like to volunteer

I am interested in being a NICU Helping Hands volunteer. Please contact me about volunteering for the following programs: *Project NICU (DFW Metroplex Only)Administrative Assistance (DFW Metroplex Only)I am a business owner and would like to discuss ways to helpAngel Gown Program (Seamstress)Beanies for Babies Program (Knit/Crochet)*check all that apply

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Additional Information *

Other: *

I am requesting: *Financial AssistanceOne-on-One MentoringAn Urgent GownOther

Financial Assistance Information

The hospitalization of a baby in the NICU can leave a family financially unprepared. If you are a current NICU family experiencing financial difficulty we may be able to assist you through our gift card program. Please let us know what type of assistance you need. Someone on our staff will contact you as soon as possible.

Hospital Name *

Contact Name & Title *

Phone

Hospital Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Social Worker Name *

Social Worker Email *

Social Worker Phone *

NICU Baby Information

Baby's Name(s) *

Gestational Age(s) *

General Overview *Diagnosis info, length of stay, special needs, family challenges, etc

Additional Information *

Our hospital is requesting: *Information on Project NICUAngel Gown® GarmentsOther

How many infant losses do you have in your hospital annually? *Please include all loss so that we can determine number of gowns you will need on an annual basis (e.g. fetal demise, stillborn, pre-viable, NICU losses, lethal congenital anomalies, etc).

Does your hospital have both L&D and a NICU?Yes, both L&D and a NICUL&D onlyNICU onlyNeither L&D or a NICU

Additional Information

Urgent Angel Gown Information

We are saddened that anyone needs an Angel Gown®, but we are honored to provide your precious child with a garment that has been lovingly made by a volunteer seamstress from a donated wedding gown. If you are requesting a garment on behalf of a friend or family member who has lost their child please be sure to confirm all information related to the gestation/age and weight of the baby. Please insure the accuracy of the shipping address you are providing before filling out this form. <ul> <li>Urgent requests are processed by 3pm Monday-Friday.</li> <li>Requests received after 3pm will be processed the next business day.</li> <li>Requests received before 3pm Monday – Friday will be shipped in the afternoon via two day FedEx.</li> <li>Requests received before 3pm on Thursday will arrive via two day FedEx on the following Monday.</li> <li>Requests received before 3pm on Friday will arrive via two day FedEx on the following Tuesday.</li> <li>Requests received on Saturday and Sunday will be processed on Monday.</li> </ul> The cost of shipping an Angel Gown® garment via two day FedEx is currently provided by NICU Helping Hands through generous donations from families, friends and other supporters. We are unable to cover the cost related to overnight shipping, however families requesting overnight service will be provided pricing and payment options to cover this service when needed. Thank you for your understanding.

Baby's Weight *Our garments and wraps are made for babies weighing only ounces up to 10 lbs. We do not have garments for babies over 10 lbs.

The gestational age of the baby at the time death *If the baby was born before 40 weeks gestation please list the exact gestation of the baby (e.g. 24 weeks). If the baby was full term please list that as well (40 weeks).

Hospital Where Baby Passed Away *

Family Name *If different from the person submitting this form.

This gown is needed for a baby *

Date of Funeral Service *

It is very important that you give us an exact date for the service so we know exactly when the gown is needed. The date of the funeral service lets us know exactly when the garment is needed for the service. We will not ship a garment without this information.

Shipping Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Shipping Options *Two day shipping via FedEx provided at no charge.Overnight shipping via FedEx. The cost of shipping an Angel Gown® garment via two day FedEx is currently provided by NICU Helping Hands through generous donations from families, friends and other supporters. We are unable to cover the cost related to overnight shipping, however families requesting overnight service will be provided pricing and payment options to cover this service when needed. Thank you for your understanding.