Infant Loss and Remembrance Day

Infant Loss and Remembrance Day Consent Form
This consent form is to obtain permission to name and honor your baby during the Infant Loss and Remembrance Day event on October 15th. The event is dedicated to commemorating the lives of infants who have passed away and providing support to grieving families.
Infant Loss and Remembrance Day
  • Event Date: October 15th
  • Event Purpose: To honor and remember infants lost by families and to offer a space for shared mourning and support.
  • Activity: During the event, the names of the honored infants will be read aloud, and there will be a moment of remembrance.
By signing this form, you agree to have your baby’s name included in the ceremony and allow it to be read aloud during the event. You may also provide a short message or memory to be shared if you wish.
Infant loss and infertility both have profound psychological impacts. Common symptoms include grief/mourning, anxiety, depression, relationship strain and can affect identity and self-image. Therapy for infant loss and infertility is a compassionate, multifaceted approach designed to support individuals and couples through profound grief and emotional pain. By addressing the unique psychological impacts and providing tailored therapeutic interventions, therapists help clients navigate their grief, rebuild their lives, and find hope and meaning beyond their losses.

If you are living while grieving the loss of an angel, and wish to participate in the Remembrance Day please fill out the consent form below.

Participant Information:
Baby's Information:
Date of Birth:(Required)
Date of Passing:(Required)
I, , hereby consent to the inclusion of my baby's name, , in the Infant Loss and Remembrance Day event on October 15th. I understand that my baby's name will be read aloud during the event and any additional message or memory provided will be shared.
Privacy Statement:
Your privacy is important to us. The information provided on this form will be used solely for the purpose of the Infant Loss and Remembrance Day event. It will not be shared or used for any other purpose without your explicit consent.
Contact Information:
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