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( ) Add to mailing list. Mail To: Bereaved Parents, USA
( ) Remain on mailing list. Coeur d’Alene Chapter
( ) Address change. P.O. Box 3504
( ) Remember the child below on special days. Coeur d’Alene, ID 83816-2517
( ) Remove from mailing list. or Email info to: coeurdalenebp@aol.com
( ) Send newsletter to email address:_______________________________________
NAME__________________________________________________________________________________
PHONE_______________________________________
ADDRESS_______________________________________________________________CITY_________________________
STATE __________________ ZIP ______________ EMAIL ADDRESS___________________________________
NAME OF CHILD___________________________________________________________________________
CHILD’S AGE _____________ CAUSE OF DEATH___________________________________________________
BIRTH DATE ______________________ DEATH DATE ___________________
SON _______________ DAUGHTER ____________
I WOULD LIKE THE NEWSLETTER DEDICATED TO MY CHILD IN THE MONTH OF: ________________
I WOULD LIKE TO DONATE $______________
IN LOVING MEMORY OF ____________________________________________________________________
Our chapter newsletter can be sent by email to help reduce postage expense. Send request to bpcdanews@aol.com
All information received will remain confidential. It will be used for internal purposes only and not shared outside our organization.
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